Medical errors are the third greatest cause of death in hospitals.
‘The real problem isn’t how to stop bad doctors from harming, even killing, their patients. It’s how to prevent good doctors from doing so.’ Atul Gawande
Terry Fairbanks is an expert on system safety.
He explains that, instead of focussing on people, we should focus on the hazards in our work environment. So we have.
See this one (indistinct chlorhexidine antiseptic)
this one (hazardous APL valves)
and this one (central line related air emboli)
Unfortunately the existing healthcare safety frameworks are fairly powerless to remove them.
The culture must change.
If we approach patient safety together we will all win. We includes patients, relatives, staff, administrators, regulators, insurers, manufacurers and everyone else.
Patients & relatives – speak up, ask questions, raise concerns. Yes we are busy but we are listening.
Front line staff – support your colleagues. Recognise hazards in your workplace. Those issues that frustrate you ‘YES’ they do need to be fixed because they impact on patient safety. Get the support of others around you. Put your solutions through a ‘Hazard Feedback Framework‘ and then present them.
Administrators – Actively seek out the voices of all your staff. Don’t just listen to those telling you what you want to hear. Move beyond the reputation of your hospital or area health service – healthcare safety needs to improve everywhere.
Regulators – Be brave. If front line staff present you with a problem then accept it as a problem. If it is not resolved it will lead to adverse patient outcomes. Don’t sit there waiting for more incident reports before acting. The nature of specific adverse events is they are dispersed in time and place. Be aware many incidents aren’t reported because staff are frustrated nothing effective is done to prevent them.
Manufacturers – Appreciate the free research and development information you will obtain from the front line. If you act on it we will all benefit.
Insurers – Provide financial incentives to those hospitals actively seeking out and presenting safety hazards. Increase premiums for those using recognised unnecessary hazards.
If we approach patient safety together we will all win.