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What do we mean by Patient Safety?

What do we mean by Patient Safety?

A fit, young woman is admitted to hospital for a routine minor surgical procedure carried out under a general anaesthetic. Twenty-four hours later she has died as the result of a series of flawed reactions to a perfectly manageable complication. A physically fit and active self-employed builder undergoes removal of a benign swelling on the side of his neck under local anaesthetic. Six months later, as a result of a nerve injury sustained during the operation, he is incapable of work on account of intractable pain and weakness in his shoulder and arm.

Such is the nature of medical catastrophes seen in Coroners’ courts, litigation and the media. Yet in none of these cases did the clinicians involved set out to do harm or behave in a purposefully reckless manner. In fact, they were intending precisely the opposite; they were trying to make their patients better.

Medical intervention always involves a degree of risk. Ensuring that such risk is minimised is a sine qua non for ‘high quality’ care. To emphasise its importance, the concept of ‘Patient Safety’ is widely applied to this aspect of healthcare.

Reporting: Learning from Experience

Almost invariably, a full-blown catastrophe can trace its origins back through a number of near-miss or low harm incidents, known as ‘precursors’. This is, of course, true for all human systems and not just healthcare. It is difficult to exaggerate the importance of detecting and paying heed to such precursors. Neglecting to do so results in highly visible medical accidents and litigation such as described in the initial paragraph. But if timely action is taken because of detection and reporting, many tragedies can be prevented.

How does CORESS help Patient Safety?

CORESS has adapted, for use by surgical teams, a system which has been operating successfully in Aviation and Marine industries since the mid 1970s. This is ‘The Confidential Human Factors Incident Reporting Programme (CHIRP)’. In brief this elicits reports of precursor events which otherwise go undetected and ‘under the radar’. The key feature is the separation of reporting, analysis and feedback from any connection to the employer or regulator – and most importantly, to preserve absolute confidentiality.

The Importance of Confidentiality

It has been shown and long accepted in Aviation and other high stakes industries such Marine and Rail that, even if mistakes have been made and although it may be the system which is mainly at fault, fear of reprisal often deters staff from reporting incidents to in-house systems. This is confirmed by experience which demonstrates that when reporting/feedback systems are clearly separate from employers, the reporting rate increases. To attract confidential reports of near-miss and low harm events, CHIRP successfully developed the concept of a third party separate from any outside agencies and which acts as an ‘Honest Broker’.

Reports received by CORESS are analysed, and the learning published regularly to a wide audience as a series of illustrative feedback cases or vignettes. Where system design or equipment problems are implicated, CORESS relays the dis-identified information to the appropriate regulator.

Understanding why things sometimes go wrong

It is generally accepted that a range of issues are usually at play in any adverse clinical event, including human factors. Based on his 5-years of work with CORESS, Professor Kapur has developed a schema, which captures five key factors, helpful to those working in the field of clinical negligence. These are as follows:

Staff, the individuals, the interactions between them e.g., fatigue, stress, and uncertainty of role etc.

  1. Environment, both physical and organisational, e.g., noise and bed pressure, respectively.
  2. Information, e.g., lack of availability on time, errors, communication failures etc.
  3. Task, which may be its complexity or timing elements within it.
  4. Patient, e.g., specific characteristics, fragility, co-morbidities etc.

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