Risk management and patient safety
Patient safety is another key aspect of health and social care quality. The World Health Organization defines patient safety as ‘the absence of preventable harm to a patient during the process of health care’ and the discipline of patient safety as ‘the coordinated efforts to prevent harm, caused by the process of health care itself, from occurring to patients’[i]. The issues of patient safety first came to prominence in the 1990s, with the Harvard Medical Practice Study in 1991 reporting that 4% of patients suffer some kind of harm in hospital[ii], and the subsequent Institute of Medicine report in 1999 estimating that medical errors in the USA cause more deaths that road traffic collisions, or breast cancer[iii]. Studies in the UK and Europe have estimated that 10% of hospital patients suffer from medical errors or harms[iv],[v].
There is a global consensus that a systems approach is required to tackle patient safety. This is based on the work of British psychologist James Reason, who concluded that safety failures are almost never caused by isolated errors, with most accidents resulting from multiple, smaller errors in environments with serious underlying flaws. Reason described this as the ‘Swiss Cheese Model’ and advocated that organisations should identify the individual holes within their systems and make changes in order to both shrink the size of the holes and create enough overlap so that the holes do not align. Reason used the terms active errors to describe errors made by individuals (which he argued are inevitable as no practitioners are able to practice perfectly) and latent errors to describe the failures of systems that allow the inevitable active errors to cause harm[vi]. There are now a number of global patient safety initiatives based on systems approaches, including the implementation of surgical checklists to promote safer surgery[vii].
In England, NHS Improvement provides guidance and tools for improving patient safety, including frameworks for managing Serious Incidents (adverse events where the consequences are so significant or the potential for learning is so great that a heightened level of response is justified) and Never Events (Serious Incidents that are wholly preventable through the implementation of national guidance or safety recommendations)[viii],[ix]. Patient Safety tools provided by NHS Improvement include a National Reporting and Learning System (NRLS) for reporting Serious Incidents, as well as a National Patient Safety Alerting System (NPSAS), which enables the dissemination of patient safety alerts to healthcare providers via a central alerting system[x],[xi]
© Flora Ogilvie 2017
[ii] Brennan TA, Leape LL, Laird N et al. Incidence of adverse events and negligence in hospitalised patients: results of the Harvard Medical Practice Study. New England Journal of Medicine, 1991, 324 (6):370-7
[iii] Kohn LT, Corrigan JM, Donaldson MS Eds. To err is human: Building a safer health system. 1999, Institute of Medicine, National Academy Press.
[iv] Department of Health. An organisation with a memory: Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. Crownright. Department of Health. HMSO. 2000.
[v] Standing Committee of the Hospitals of the EU. The quality of health care/hos- pital activities: Report by the Working Party on quality care in hospitals of the sub- committee on coordination. September 2000.
[vi] Agency for Healthcare Research and Quality. Patient Safety Primer: Systems Approach. 2015. https://psnet.ahrq.gov/primers/primer/21/systems-approach
[vii] WHO. Patient safety programme areas
[viii] NHS England. Serious Incident Framework. 2015 https://improvement.nhs.uk/uploads/documents/serious-incidnt-framwrk.pdf
[ix] NHS England. Never Events Policy and Framework. 2015 https://improvement.nhs.uk/uploads/documents/never-evnts-pol-framwrk.pdf
[x] NHS Improvement. Learning from patient safety incidents. https://improvement.nhs.uk/resources/learning-from-patient-safety-incide...
[xi] NHS Improvement. Patient Safety Alerts. https://improvement.nhs.uk/resources/patient-safety-alerts/