The Healthcare Safety Machine Needs Fixing

The healthcare safety machine needs fixing. Is there anyone out there who can help?


Medical errors are the third greatest cause of death in hospitals.


We know this.

‘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.

Watch his video here.

He explains that, instead of focusing on people, we should focus on the hazards in our work environment. So we have.

See this one (tinted pink chlorhexidine)

This one (hazardous APL valves)

and this one (central line related air emboli)

Unfortunately existing safety frameworks seem too unwieldy 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 hazard then accept it as a hazard. 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 of the limiations of current reporting systems, and don’t let them impede you introducing effective safety solutions.

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 incentive to those hospitals actively seeking out and presenting safety hazards. complex-machine

If we approach patient safety together we will all win.

3 thoughts on “The Healthcare Safety Machine Needs Fixing

  1. More regulation, policing, written guidance will not deliver results.

    The least used resource in patient safety is the patient and the family. We need to find ways of improving this.

    Technology is a big enabler as well eg electronic prescription and bar coded dispensing.

    Culture, by far is the most important and the most difficult to change. This needs a paradigm shift at societal level as well.


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