http://bmj.com/cgi/content/full/323/7313/585
BMJ 2001;323:585-586 ( 15 September )
Editorials
Delivering safe health care
Safety is a patient's right and the
obligation of all health professionals
or even about such harm when it
occurs.
Recent studies in the United States, Australia, and the United Kingdom and
reports from the US Institute of Medicine and the UK Department of
Health have drawn attention to the chronic "unsafeness" of
health systems worldwide.1-7
This attention is not new. What is new is that preventable,
iatrogenic injuries are being quantified and openly discussed. For
example, adverse drug reactions have become a national issue in the
United Statesstudies show that adverse drug
events occurred in 6.5% of hospitalisations.8 By
calling for solutions, these reports have highlighted the tensions between
accountability and improvement, needs of individual patients and
benefit to society, and production goals and safety.
Most causesand solutionslie in the systems of care and how we work.
Healthcare professionals, however, focus energy on individual patients,
tackling difficulties in the system as they appearoften as separate problems and not
in parallel. Individual care is of course crucial. But unless
attention is given to the system our patients are at risk from a
faulty service. For example, inadequate handovers can mean that
vital information is lost between different care givers and
services. Is it that the word "system" is anathema to many
doctors? Just getting health professionals to work harder or
exhorting them to be safer will not help; the system of care must be
redesigned. We must instil a chronic sense of uneasea constant awareness of risk in
every action.9
Such attention to risk enables crews of aircraft carriers to launch
and land several planes every day on decks the size of two football
fields with virtually no adverse events. All hands know that one
oversight can lead to disaster.10
Theories of quality improvement in complex systems have helped the
understanding of safety in health care. Safety is the aim, and
improving skills and techniques is the method to get there. Much is
known about how to build safer systems and reduce risk, but little
of this knowledge is embedded in health careand until it is, the sustained
changes in behaviour of individuals and organisations that are
needed for safer care are unlikely. Punishment will not help.
The knowledge, skills, and attitudes needed for safe practice are not
normally acquired in medical school. The disciplines in which risk
management and quality improvement are important are wide ranging
and cut across professional, clinical, and organisational boundaries.
Some of these disciplinescognitive psychology, ethics, bioengineering,
mathematics, statistics, information science, ethics, and lawwill be familiar. Otherschange management, team work,
organisational behaviour, systems theory, disaster analysis, and
human factorsmay not be. Not all these disciplines need be
given their own space in the curriculum, but each should support the
development of understanding about safety. How long, though, should
we wait before all medical schools and training programmes include
safety of patients as a central objective?
Doctors have mostly avoided the question of how safety can become central to
their work. Employing an expert will not reduce harm. A general call
to embrace safety may influence a few people but will not change
systems. Care will be safer when we learn to work as teams and
understand the team as a microsystema small, focused, organised unit
with a set of patients, technologies, and practitioners.11 Some
important changes that health professionals can make may be very low
tech and seem trivial. How would methicillin resistant Staphylococcus
aureus survive if all doctors always washed their hands after
examining a patient? We know this would make a difference. The
difficulty lies in implementing what we know.
Improving safety of patients should be one of the highest priorities of healthcare
leaders. Perhaps things are changing. In the United Kingdom the
National Patient Safety Agency has just been set up, and in the
United States President Bush has increased the budget of the Agency
for Healthcare Research and Quality by $100m to promote research on
safety of patients.12
Easy access to research on improving safety may help doctors and other
health professionals make care safer. Quality in Health Care,
a journal of the BMJ Publishing Group, has included papers on safety
in the past. From March 2002 the journal will become Quality
and Safety in Health Care. It will continue to publish papers on
quality improvement but will include more papers on safe care and
safe practice. We invite readers to send us these. Changing
attitudes and practices will be hard work. Patients are being placed
at unnecessary risk and many are harmed; they expect that we will
offer safer care.
Paul Barach
Center for Patient Safety, Department of
Anesthesia and Critical Care, University of Chicago, Chicago, IL
60637, USA (pbarach@airway.uchicago.edu)
Fiona Moss
|
1. |
Brennan TA, Leape LL, Laird L, et al. Incidence of adverse
events and negligence in hospitalized patients: results of the Harvard
Medical Practice Study I. N Engl J Med 1991; 324: 370-376 |
|
2. |
Wilson RM, Runciman WB, Gibberd RW, et al. The quality in
Australian healthcare study. Med J Aust 1995; 163: 458-471 |
|
3. |
Vincent C, Neale G, Woloshynowych M. Adverse events in
British hospitals: preliminary retrospective record review. BMJ 2001;
322: 501-502 |
|
4. |
Institute of Medicine. To err is human: building a
safety health system. Washington, DC: National Academy Press, 1999. |
|
5. |
Department of Health. An organisation with a memory.
Report of an expert group on learning from adverse events in the NHS. www.doh.gov.uk/orgmemreport/
(accessed 7 Sep 2001). |
|
6. |
Committee on Quality of Health Care in America, Institute
of Medicine. Crossing the quality chasm: a new health system for the 21st
century. Washington, DC: National Academy Press, 2001. |
|
7. |
Department of Health. Building a safer NHS for
patients. Implementing an organisation with a memory. www.doh.gov.uk/buildsafenhs/
(accessed 7 Sep 2001). |
|
8. |
Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi
D, et al. Incidence of adverse drug events and potential adverse drug events:
implications for prevention. ADE Prevention Study Group. JAMA 1995;
274: 29-34 |
|
9. |
Reason J. Managing the risks of organizational
accidents. Aldershot, Hampshire: Ashgate, 1997. |
|
10. |
Weick KE. Organizational culture as a source of high
reliability. Calif Manage Rev 1987; 24: 112-127 |
|
11. |
Donaldson MS, Mohr JJ. Exploring innovation and quality
improvement in health care micro-systems: a cross case analysis.
Washington, DC: National Academy Press, 2000. |
|
12. |
Report of the Quality Interagency Coordination Task Force
(QuIC) to the president. Doing what counts for patient safety: federal
actions to reduce medical errors and their impact. www.Quic.org |
|
||||||||||
|
|
Rapid Response responses to
this article:
Read all Rapid Response
responses
Motherhood statements - again
Diane Campbell, Itinerant Emergency
Physician , Bunbury Hospital, WA
bmj.com, 16 Sep 2001 [Response]
Comparing medicine and aviation safety
Andrew Herd, GP , County Durham
bmj.com, 17 Sep 2001 [Response]
A public health lesson
Stephen Workman, Assistant Professor
, Dalhousie University Department of Medicine
bmj.com, 17 Sep 2001 [Response]
Other related articles in BMJ:
EDITOR'S CHOICE
Promoting safety and quality.
BMJ 2001 323: 0.
EDITOR'S CHOICE [GP]
Promoting safety and quality.
BMJ 2001 323: 0.
ALL INFORMATION, DATA,
AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION
PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR
OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING
MEDICAL OR LEGAL ADVICE. THE DECISION WHETHER OR NOT TO VACCINATE IS AN
IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN
CONSULTATION WITH YOUR HEALTH CARE PROVIDER.