xiii
1 Progress and Challenges for Patient Safety. . . 1
Progress on Patient Safety . . . 1
Harm Has Been Defi ned Too Narrowly . . . 3
Safety Is a Moving Target . . . 5
Only Part of the Healthcare System Has Been Addressed. . . 6
We Are Approaching Safety in the Same Way in All Settings . . . 6
Our Model of Intervention Is Limited . . . 7
Healthcare Is Changing . . . 8
References . . . 10
2 The Ideal and the Real. . . 13
The Day-to-Day Realities of Healthcare . . . 14
Comparing Actual Care with the Care Intended by Guidelines . . . 14
Reliability of Clinical Systems in the British NHS. . . 15
Following the Rules: Reliability of Human Behaviour. . . 15
The Ideal and the Real: Five Levels of Care . . . 17
The Cumulative Impact of Poor Quality Care . . . 18
Explicit Discussion of the Real Standard of Care Is Critical. . . 21
What Is the Impact of Improving Quality Standards? . . . 22
Levels of Care and Strategies for Safety Improvement . . . 23
References . . . 25
3 Approaches to Safety: One Size Does Not Fit All . . . 27
Approaches to Risk and Hazard: Embrace, Manage or Avoid . . . 27
Three Approaches to the Management of Risk . . . 29
Embracing Risk: The Ultra-adaptive Model . . . 30
Managing Risk: The High Reliability Approach . . . 30
Avoiding Risk: The Ultra-safe Approach . . . 31
Rules and Adaptation. . . 32
How Many Models for Healthcare?. . . 33
Moving Between Models . . . 34
Refl ections on the Safety Ideal . . . 35
References . . . 36
xiv
4 Seeing Safety Through the Patient’s Eyes . . . 39
What Do We Mean by Harm? . . . 40
Safety and Quality of Care from the Patient’s Perspective . . . 41
Safety Through the Patient’s Eyes . . . 44
The Patient Potentially Has the Most Complete Picture . . . 44
The Healthcare professional’s View is Necessarily Incomplete. . . 44
The Resources of the Patient and Family Are Critical to Safe Care . . . 44
Coordination of Care Is a Major Safety Issue. . . 45
Rethinking Patient Safety . . . 45
References . . . 46
5 The Consequences for Incident Analysis. . . 47
What Are We Trying to Learn When We Analyse Incidents? . . . 47
Essential Concepts of ALARME . . . 50
Select Problems for Analysis Which Are Important to Patients . . . 50
Widen the Time Frame of Analysis: Review the Patient Journey . . . 52
Success and Failure in Detection and Recovery . . . 55
Adapting the Analysis to Context . . . 56
References . . . 58
6 Strategies for Safety. . . 59
What Options Do We Have for Improving Safety? . . . 59
Five Safety Strategies. . . 60
Strategy I: Safety as Best Practice . . . 61
Strategy II: Improvement of Work Processes and Systems . . . 62
Strategy III: Risk Control. . . 64
Strategy IV: Monitoring, Adaptation and Response . . . 65
Strategy V: Mitigation . . . 67
Innovation . . . 68
Selection and Customisation of Strategies to Clinical Context . . . 69
References . . . 71
7 Safety Strategies in Hospitals . . . 73
A Little History . . . 73
The Enthusiasm of the Early Years, 1995–2002 . . . 74
The Advent of Professionalism 2002–2005 . . . 74
Safety Culture, Multifaceted Interventions, and Teamwork 2005–2011 . . . 74
Refl ections on Safety in Hospitals . . . 75
Safety in Hospital: Distinguishing Current and Future Strategies . . . 75
Safety as Best Practice . . . 77
Improving the System . . . 77
Reducing the Burden on Staff: Simplifi cation and Decluttering . . . 78
Contents
Risk Control . . . 80
Control of Medication . . . 80
Potential for ‘Go and No-Go’ Controls in Surgery . . . 80
Placing Limits on Care . . . 81
Monitoring, Adaptation and Response . . . 82
Patients and Families as Problem Detectors . . . 82
Team Training in Monitoring, Adapting and Response . . . 83
Briefi ngs and Debriefi ngs, Handovers and Ward Rounds. . . 83
Mitigation. . . 84
Support Systems for Staff and Patients . . . 84
Regulatory and Political Determinants of Approaches to Safety . . . 85
Safety in Context: The Many Hospital Environments . . . 87
References . . . 90
8 Safety Strategies for Care in the Home . . . 93
An Ageing Population and the Expansion of Home Care . . . 93
The Challenges of Delivering Healthcare in the Home . . . 94
The Hazards of Home Care: New Risks, New Challenges . . . 95
Accidental Injury in the Home . . . 95
Adverse Events in Home Care . . . 96
Adverse Drug Events . . . 96
Risk to Family and Other Care Givers . . . 96
Problems of Transition and Coordination . . . 97
Infl uences on Safety of Healthcare Delivered in the Home. . . 97
Socio-economic Conditions Take on a Much Greater Importance. . . 97
The Home Environment as Risk Factor . . . 98
Increasing Responsibilities of Carers . . . 98
The Training and Experience of Home Care Aides . . . 100
Fragmented Approach of Healthcare Professionals . . . 100
Safety Strategies and Interventions in the Home . . . 100
Optimization Strategies in Home Care: Best Practice and System Improvement . . . 101
Discharge Planning and the Journey from Hospital to Home. . . 102
Training of Patients and Carers . . . 102
Risk Control Strategies in Home Care. . . 103
Monitoring, Adaptation and Response Strategies in Home Care . . . 104
Detecting Deterioration. . . 105
Mitigation. . . 106
The Responsibilities of Carers . . . 106
Mitigation Strategies in Home Haemodialysis . . . 107
Refl ections on Home Care Safety . . . 107
References . . . 109
xvi
9 Safety Strategies in Primary Care . . . 113
Challenges for Primary Care . . . 113
The Nature of Risk in Primary Care . . . 114
Error and Harm in Primary Care. . . 115
Diagnostic Errors . . . 115
Safety as Best Practice . . . 116
Improving the System . . . 118
Risk Control Strategies . . . 119
Control by Assessment of Competency . . . 119
Control of Hazards . . . 120
Monitoring, Adaptation and Response . . . 120
Developing a More Systematic Approach to Watching and Waiting . . . 121
Improving Transitions Between Hospital and Primary Care . . . 121
Mitigation. . . 123
Refl ections on Safety in Primary Care. . . 123
References . . . 125
10 New Challenges for Patient Safety. . . 129
The Changing Nature of Healthcare . . . 129
Improved Safety in Some Contexts . . . 131
New Challenges for Patient Safety . . . 131
Increasing Complexity . . . 132
The Challenges and Risks of Care Coordination . . . 132
The Benefi ts and Risks of Screening . . . 133
The Benefi ts and Risks of Information Technology . . . 133
The Burden of Healthcare: Impact on Patients and Carers . . . 134
A Global Revolution Rather Than a Local Evolution . . . 135
References . . . 137
11 A Compendium of Safety Strategies and Interventions. . . 139
Seeing Safety Through the Patient’s Eyes . . . 139
Considering Benefi t and Harm Along the Patient Journey . . . 140
Patient Safety as the Management of Risk Over Time . . . 141
Adopting a Range of Safety Models . . . 142
Developing a Wider Range of Safety Strategies . . . 144
A Compendium of Safety Strategies . . . 145
References . . . 150
12 Managing Risk in the Real World . . . 151
Implications for Patients, Carers and Families . . . 151
Implications for Frontline Clinicians and Managers . . . 152
Implications for Executives and Boards . . . 154
Implications for Regulatory Agencies and Government . . . 155
Future Directions for Research and Practice . . . 157
Contents
xvii
Fig. 2.1. Five levels of care
Fig. 2.2. Optimisation and risk management Fig. 3.1. Three contrasting approaches to safety Fig. 4.1. Four patient journeys
Fig. 4.2. Varying standards of care over time Fig. 5.1. Analysis of safety along the patient journey Fig. 5.2. A case analysed with ALARME
Fig. 6.1. Analysis, context and strategies
Fig. 7.1. Improving systems reduces the need for adaptation Fig. 7.2. Guidelines for fractured neck of femur in the fi rst 24 h
Fig. 7.3. Safety strategies in peri-operative care in Europe and the United States
