Search Results

This chapter considers how neuroergonomics—the study of the brain and behavior at work in healthy and impaired states—is relevant to assessments and interventions in patient safety at the levels of individuals and health care systems. It reviews potential areas for neuroergonomic interventions at the level of individuals and systems, and cultural and legal issues that affect the ability to intervene.

This chapter reflects on the UK Government's approach to tackling patient safety, and the complexities that arise with respect to developing the evidence base on which it is supposed to depend. It explores the problems that arise in estimating the scale of the patient safety problem, including those associated with the definition and measurement of ‘adverse events’ and ‘near misses’. Approaches that seek to make a causal link between medical interventions and harmful outcomes, and those that advocate whole system analysis are critically discussed. The chapter reviews the problems that arise in requiring staff to report on errors, including those of judgement and defensiveness. It concludes with a review of the continuing challenges of the patient safety agenda, and the balancing act between risk aversion and the development of cutting edge treatments.

This chapter presents an overview of clinical governance. It discusses the meaning of clinical governance, origins of clinical governance, and the regulatory bodies tasked with the assessment of clinical governance by regulatory bodies. It then describes the Patient Safety First Campaign, which was launched within the National Health Service (NHS) in England in 2008 to make the safety of patients the highest priority and make all avoidable death and harm unacceptable.

Risk identification is key to a comprehensive risk management program that include clinical, operational, and financial risks. All NHS institutions are required by the National Health Service Litigation Authority (NHSLA) Risk management Standards for Acute Trusts to have a systematic approach to clinical risk management, since it is a fundamental part of the provision of safe, effective healthcare. This chapter discusses patient safety incident reporting, claims and complaints, clinical audits, morbidity and mortality meetings, executive safety walkrounds, proactive risk assessment, national reports and surveys, and patient safety alerts.

Patient feedback and the associated assessment of the performance of health care professionals has increased in prominence in recent years. This is attributed partly to concerns around patient safety and the resultant efforts to improve performance. This chapter discusses the evolution of patient surveys, the National Patient Survey Programme (NPSP), patient priorities, the importance of patient feedback in shaping improvements, and optimizing the use of patient feedback.

This chapter discusses the challenge of communicating with the media and the public about healthcare quality and safety. The task is made difficult by factors such as the complexity of messages, risk of creating anxiety amongst those for whom care is provided, and fast moving and often hostile media environment. The reciprocal relationships between NHS staff, the communities they serve, and external media sources can be powerful tools to support change but must be managed effectively.

This chapter discusses the following topics: aspects of quality in health; quality improvement methods; clinical audit; patient safety; evidence-based practice; clinical guidelines; and getting knowledge into practice.

Risk awareness is the recognition of the potential for hazards, risks, and incidents that occur within the healthcare environment and result in patient harm. Being risk aware means that individuals and organizations are potentially able to prevent error and subsequent harm to patients by putting plans and contingencies in place. Within organizations an effective patient safety culture is said to exist when there is high awareness of safety issues at all levels from Trust Board to Ward. This chapter discusses factors which help improve risk awareness, barriers to effective action, and tools which help improve risk awareness.

This chapter discusses the importance of patient and public involvement (PPI). PPI increases the accountability of the NHS to the taxpayer. PPI can support service improvement and the concept of co-design which draws from patient and staff experience is being adopted in health care settings. Section 242 of the NHS Act 2006 requires health services to make arrangements to involve those who use services and the Darzi Review (2008) reinforces this as part of the new national quality framework.

Safety activity is prevalent, but little of value is produced. Several scandals tainted the patient safety movement. Diagnostic “error” became popular but in a highly medicalized way vulnerable to hindsight bias. Safety science moved on from linear, complicated models to emergent, interactive models based on complexity. In 2015, 15 years after the IOM report, four separate reports on the state of patient safety concluded that it had accomplished little and that the approach to safety must be changed dramatically. But the change they recommended was no different from that recommended in the Institute of Medicine report 15 years earlier.

This chapter describes the silent worldwide epidemic of medical error, and outlines what is known about the manner in which human cognitive limits and system complexity contribute to problems in patient safety. It then discusses the manner in which sleep deprivation, circadian misalignment, and sleep inertia contribute to the genesis of error, and reviews the literature on the relationship between sleep deprivation, work hours, and healthcare provider performance. It presents the results of recent cohort studies directly measuring the effects of sleep deprivation on safety, along with the results of intervention studies designed to mitigate its effects. The chapter concludes with a brief discussion of current healthcare provider work hour policies in Europe and the United States, and the future healthcare policy implications of this emerging work.

Unbridled optimism and a flurry of organizational activity followed the publication of To Err is Human. As patient safety became corporatized into new institutions and programs; it became mainstreamed and adopted by organized healthcare. Patient safety became dominated by a measure and manage approach. US hospitals added patient safety to existing quality, risk management and regulatory compliance bureaucracy. This internalization and incorporation led to a closing off of patient safety from influences outside of healthcare. Infection control and health information technology began to dominate safety efforts. Safety culture became a popular topic but in a narrow and instrumental way.

Risk assessments are undertaken to estimate the consequences and likelihood of a particular risk being realized. This chapter discusses risk assessment in healthcare, the risk assessment process, assessing severity of risks, and implementing successful risk assessment.

This chapter discusses clinical information systems (CIS). When properly implemented, clinical information systems can improve patient safety and reduce medical error. Decision support is a powerful tool to reduce errors of omission and commission. Clinical information systems can enhance the quality and reduce the burden of clinical audit. Unless users can be actively engaged, new systems are likely to fail.

This chapter expounds on Chapter 5, which exemplifies the bottom-up change in the United Kingdom. It particularly discusses the bottom-up change initiated in hospitals in the United States. One of the strongest, broadest initiatives for change in health care organizations across the industrialized world has been the push to improve patient safety, clinical outcomes, and overall productivity. Theoretically at least, these changes might offer something to all the key stakeholders. If one assumes that provision of the highest quality clinical care is a universal priority, then these initiatives should be broadly appealing. In the best-case scenarios, administrators and policymakers suggest that certain performance enhancements can work as panaceas, producing more efficient (lower cost) health care with better clinical results.

Sociological interventions in national improvement programs are the topic of this chapter. It deals with a sociological evaluation of a large improvement program for care of older adults. This was a patient safety quality improvement collaborative that presented a narrow definition of ‘useful’ research in which social scientists are supposed to discover the factors that support or hamper the implementation of existing policy agendas. Such definitions are unfortunate, since they undo the capacity to complexify the taken-for-granted conceptualizations of the object of study that is crucial for situated intervention research. As an alternative to this definition of ‘usefulness’, this chapter explores a focus on multiple ontologies in the making when studying patient safety. Through this focus, social scientists become involved in refiguring the problem space of patient safety, the relations between research subjects and objects, and the existing policy agendas. This role gives social scientists the opportunity to focus on which practices of ‘effective care’ and ‘participation’ are enacted through different approaches to dealing with patient safety and what their consequences are for the care practices under study. Such a focus on multiple ontologies of safety opens up new ways for intervention in quality improvement collaborative, but also points to the limitations of evaluation as intervention.

Clinical networks are described as linked groups of health professionals and organizations from primary, secondary, and tertiary care, working in a co-ordinated manner, unconstrained by existing professional (and organizational) boundaries to ensure equitable provision of high-quality and clinically-effective services. This chapter discusses the types of networks, engagement in clinical networks, and clinical governance and improving patient safety across a network.

This chapter shows that despite all the national attention on the issue of medical errors, surprisingly little progress has been made in implementing error reduction systems. This is partly because meaningful financial incentives for health care providers to adopt patient safety measures have been lacking. In principle, tort liability could provide such incentives, but not as it is currently structured in the medical field. And under the best of circumstances, tort liability is only one of several policy instruments that can be applied to make medical care safer than it is now. The threat of a lawsuit would presumably deter such errors, but there is empirical evidence that such errors are widespread, and some experts even argue that medical malpractice has been counterproductive in achieving the objective of reducing medical error rates.