Patient Safety Module

MOPH Manticao
June 14, 2022
 Introduction
It is a sad fact that healthcare can actually harm the people that it
should be helping. This is true and alarming. However, healthcare
is a complex process, and it is not surprising that patient safety can
be threatened.

However, if the basic principles were applied then patient safety would
substantially improve.
 What is Patient Safety?
Patient safety is a health care discipline that emerged with the evolving
complexity in health care system and the resulting rise of patient harm
in health care facilities.

It aims to prevent and reduce risks and harm that occur to patients
during provision of health care
 Why do threats to patient safety occur?
The investigation of many threats to patient
safety has shown that there are usually multiple
causes and they tend to occur when there is an
unfortunate combination of ‘active failures’ and
‘latent fail' (Fig. 2.1).
Active failures are usually associated with
human factors. Occasionally there can be a
sudden and unexpected failure of equipment
but this is rare. These active failures contribute
to most threats to patients. However, latent
failures are ‘errors waiting to occur’ and are
associated with the healthcare system. These
latent failures are the root cause of most active
failures.
I. Human factors

Healthcare workers are at the ‘sharp end’ – professional

expertise is applied, the effects are immediately noticed and
it is where any threats to patient safety are seen.
At the sharp end, ‘active failures’ occur. Healthcare workers
have to make decisions and actions occur that contribute to
unsafe patient care (i.e. errors of commission). They may
also omit key steps in a clinical task (i.e. errors of omission).
These ‘failures’ are more likely if the healthcare worker is
dealing with complex events, high levels of uncertainty,
time pressures and fatigue (Box 2.1).
Cognitive psychology has identified the main types of error
due to human factors (Fig. 2.2):
• Slips. These commonly occur when there is a distraction
during a routine task. Examples include being interrupted
whilst preparing an injection so that the wrong dose is
drawn up into the syringe, and confusing the names of drugs
when overtired. The person is not aware that the slip has
occurred until after the event.
• Lapses. These occur when a standard approach, such as a
protocol or guideline, is not followed. Individuals recognize
that they are not following the particular advice but choose
not to follow the advice. An example is when a healthcare
worker is faced with a complex clinical situation and chooses
not to follow a guideline because it does not easily apply to
the problem that they are deal_x0002_ing with.
• Mistakes. These occur when there is a failure in
judgement. Mistakes often occur when the healthcare
professional has insuffi cient knowledge about a problem,
either in diagnosis or in treatment. Alternatively, mistakes
can also occur because an incorrect rule is applied to solve a
problem – these types of errors are called rule_x0002_based
mistakes.
• Violation. There is a deliberate attempt not to follow
accepted approaches. These events are rare.
The healthcare system
Healthcare managers, policy-makers and regulators are at the ‘blunt end’ – they decide on how the care is delivered
through policies, financial controls and management of the work of the healthcare professionals (Figs 2.3–2.4).
At the blunt end, ‘latent conditions’ occur (Box 2.2). A
working environment is created that increases the
probability that there will be an active failure at the
sharp end. There are a lot of latent failures – all with
the potential to cause an adverse event.

An example is when the healthcare system is

overloaded, such as overbooking admissions onto a
ward. This may be compounded with insufficient staffi
ng. Usually there is a combination of several small
factors, each appearing to be insignifi cant when
viewed alone (Box 2.3).

When latent failures occur in combination with only

one active failure, such as a mistake in drug dose by a
healthcare worker who is overtired because he or she
has been working a series of long shifts, the result is a
recipe for an adverse event to occur.
The role of the individual in patient safety
Until recently, the commonest approach to looking at patient safety has
been to focus on the errors and violations of the individual healthcare
worker.

This has now changed to a systems approach, which sees causal factors
as part of the system as a whole. However, the individual healthcare
worker is a crucial factor in the provision of safe care, and it is
important that this aspect is not ignored.
Recognizing individual problems
Some individual factors that impact on safety, such as
inexperience or distractions, will apply to all
healthcare workers at some point in their careers and
so require organizational polices to address them.
Other factors will be true for some individuals but not
others, and these involve psychological or physical
health problems, and particular personalities.
Psychological problems include stress, depression,
anxiety and psychotic disorders, as well as alcohol and
other drug use (Fig. 2.5).
Are some people naturally risky?
The concept of the risky personality has a long research
literature, relating it primarily to increased activity in risky
activities outside the workplace, but also shown to be related to
less safe practices in healthcare workers.

Risk perception also varies: some people can see danger more
easily than others, with clear benefits to safety. This can be
encouraged by increasing mental readiness. By visualizing each
case (such as each operation) in advance it is possible to
increase safety by anticipating the risks that might occur and
how they might be remedied (Fig. 2.6).

Personality can play a part in unsafe care in other ways as well.

Under stress the strengths and values of health care providers
can show a darker side: autonomy can become arrogance;
competence can lead to a sense of invulnerability; the
application of science may develop into being simply
obstructive; and collegiality can become a conspiracy of silence.
Having a clear Head Exhaustion

Alcohol use and abuse are also common among Risky behaviours are not just a function of
both male and female health care providers and personality, but can be increased through tiredness.
are often related to depression.
Other drug abuse is also rising and is a major Pilots subjected to strenuous night flights with sleep
cause of referrals to programmes for impaired deprivation show increased impulsiveness as well
health care providers. as being clumsier and having lower mood.
There remains a very tolerant culture within
medicine that still tends to ignore its gravity and Increasing evidence from around the world shows
the consequences for the doctor and the patient. that errors are more likely with overwork and a lack
of sleep.
Technology and patient safety
The use of technology is ideal when large amounts of
data have to be quickly managed. Computers do not get Patient safety can be improved by applying
bored with repetitive tasks or become tired or stressed engineering principles to the design and
– the ideal conditions for humans to make errors. evaluation of procedures. The use of technology
usually requires a clear analysis of the task to be
Technology has a major role in the improvement of performed.
patient safety, as it does in all high-risk industries.
Routine procedures can be replaced or monitored. This can identify potential problems and result in
Healthcare providers can be notifi ed when there are better-designed [Link] importance of
deviations to the expected course, such as the use of an technology in the future development of patient
alarm to alert anaesthetists in an operating theatre safety will substantially increase. There will be
when the patient’s oxygen level falls. Decision-making increasing computerization of medical records
can be improved, either at the time of diagnosis or and in the ordering and monitoring of prescribing.
when there are prescribing decisions (Fig. 2.7).
However, the greatest impact is likely to be the
However, a paradox is that procedures that become introduction of persuasive technologies that are
highly reliant on technology can increase error because designed to change people’s attitudes and
the operators still have behaviours. Examples include devices that
human infallibility and may choose to ignore prompts constantly monitor the performance of a surgeon
or misinterpret information, especially if there is and give feedback on performance, or those that
malfunction of the technology. help people to rehearse complex procedures.
II. Diagnosis

Diagnosis is the usual first step in any process of healthcare.

Subsequent management is dependent on making an
accurate diagnosis.
Often a cascade of errors is set in place, with a sequence of
errors indiagnosis and treatment that results in harm, or
potential harm, to the patient (Box 3.1).
Harm associated with diagnosis is the commonest threat to
patient safety in both primary and secondary care.
 The extent of threats to patient safety
associated with diagnosis
Primary care
Fifty-four percent of all adverse events reported in medico-
legal databases are the result of failure or delay in diagnosis,
and 25% of all adverse events are due to a wrong diagnosis.
The largest categories are malignant neoplasms and
septicaemia, including meningococcal septicaemia. Other
categories are diseases of the circulatory system, including
chest pain and peripheral vascular occlusion, and injuries.
There is often over-reliance on normal investigations and
lack of appropriate [Link] reporting of events
that caused, or had the potential to cause, harm reveals that
53% are due to missed or delayed diagnosis. There is a range
of causes (Box 3.2).
Secondary care
Twenty-one percent of all adverse events reported in
medico-legal databases are the result of failure or delay in
diagnosis. Twenty percent of reviewed deaths are
misdiagnosed, and 44% of these cases would have been
treated differently if the correct diagnosis had been made.
 Causes of threats to patient safety
associated with diagnosis
Making a diagnosis in both
primary and secondary care is not
an easy task, especially when the
presented problems are complex
(Box 3.3).
 The diagnostic process
Taking a full history, examining the patient fully and performing a
wide range of investigations are not only potentially wasteful of time
and resources but do not guarantee that a correct diagnosis will be
made; some investigations may actually harm the patient. Most of
these aspects are dependent on effective communication between
doctor and patient.
A diagnosis is made by generating and ranking appropriate
diagnostic possibilities. The most important approach is to
make an estimate of the likely cause, or causes, of the
patient’s symptoms.
The potential seriousness of each of these possibilities is
then considered, and also how amenable they are to
treatment. For example, hypothyroidism is an uncommon
cause of tiredness, is potentially serious but can be easily
treated. Very rare and novel conditions are often
considered, especially if there is previous personal
experience of these conditions, but it is important that the
applicability to the particular patient is considered (Box 3.4).
 Problems in the diagnostic process
Making a diagnosis is complex, and there are
many factors associated with problems in this
process. Among the most common pitfalls
are: maintaining a focus on a particular
diagnosis, ignoring or
not pursuing alternative hypotheses, and not
ruling out competing
hypotheses when they are very unlikely. This
latter process often results in numerous
investigations being performed. It is
important to
remember that a positive test when there is a
low possibility of the
disease is more likely to be a false-positive.
This can lead to inappropriate, and possibly
harmful, interventions (Boxes 3.5–3.7).
Doctor–patient communication difficulties
in making a diagnosis
An essential aspect of making a diagnosis is effective communication so that a full
history is obtained, the health beliefs of the patient and carer are identified, and
there is a shared understanding of the presented problem and the proposed
management plan.
 Cultural aspects in making a diagnosis

Individuals each have their own set of values and beliefs. Identifi cation
of these will help the healthcare provider to understand the individual
and his or her unique perspective on the world. It will also reveal
values and beliefs that are collectively held by a particular cultural
group. It is important not to discount views that are different from
those of the interviewer.
The attribution of the symptoms by the patient may help in the
diagnostic process, especially when the diagnosis is specifi c to a
particular culture. It is always important to listen to what the patient,
and carer, is telling the healthcare provider.
 Difficulties associated with the use of
Tele-consultations

The majority of consultations are still face-to-face but there are

increasing numbers of consultations by videocall, telephone and e-
mail.
These consultations create difficulties with communication and can
lead to major diagnostic errors. There is a lack of nonverbal cues, and
the patient’s condition and context cannot be easily determined. It is
essential to be more vigilant when using these alternative methods of
communication.
Causes of threats to patient safety associated
with diagnostic results management
Over 70% of GP practices in risk reviews have There is no foolproof system but important features
identified results handling as a major risk area. include:
Patients usually assume that their doctor will notify • Fully and legibly complete both the request form and
them of the result, but this is often not the case for a the sample.
variety of reasons.
• Make a record of the result and set a review date.
The process of performing even a simple diagnostic
test is complex, and many people may be involved. • Reconcile each result received with the tests taken.
The essential steps include taking the sample, • Ensure that all abnormal results are seen by a doctor
processing the sample, processing the results and and that prompt actions are taken.
taking action. All of these steps are vulnerable and • Ensure clinical decisions or actions relating to the
can result in a threat to patient safety. results are recorded in patients’ notes.
Particular care has to be taken for high-risk results, • Inform patients of the results.
such as pregnancy tests and those used for
monitoring treatment with drugs, such as lithium or • Audit compliance with these actions regularly.
anticoagulants. This advice is equally applicable to secondary care
providers but the extent of these factors in secondary
It is good practice for all healthcare providers to care is often unknown.
establish effective systems for results handling.
 Causes of threats to patient safety
associated with referrals
Referral from primary to secondary care is An important cause of delay in referrals for
often an important part of the diagnostic serious illnesses, such
process but it is a common cause of threat as chest pain or suspected cancer, is lack of
to patient safety, especially because there adherence to early referral guidelines – the
may be a lack of or delay in referral. urgent ‘two-week referrals’. The early detection
Referrals may be inadvertently lost, of many cancers can be difficult because the
symptoms are often nonspecific, yet this is the
especially when there is a delay between
most appropriate time for urgent referral.
the decision to refer and the actual referral
letter being produced. The referral may be
‘lost in the system’. In primary care, the
‘referral system’ can be complicated, with
numerous steps between seeing the patient
in primary care and the patient being seen
in secondary care.
 Practical approaches to reducing adverse
events associated with diagnosis
Several approaches can be taken that can reduce adverse events associated with diagnosis:
• Take a history that concentrates on the key elements.
• Assess the evidence and consider the possible range of differential diagnoses.
• Use diagnostic tests appropriately. It is important to be aware of the sensitivity and specifi
city of the screening test.
• A test with a high sensitivity will have fewer missed diagnoses.
• A test with a high specifi city will have fewer false alarms.
• A positive test when there is a low possibility of the disease is more likely to be a false-
positive.
• Carefully consider whether discharge from care is appropriate.
• Obtain a second opinion if the problem remains unexplained.
III. Medications

Medicines are the most commonly used clinical

intervention. Every day, around 1.8 million
prescriptions are written by general practitioners in
Philippines, with an additional 0.5 million
prescriptions written in hospitals.
Ensuring the safe and efficacious use of medicines is
achallenging and complex process.
It is an unavoidable fact that medicines that bring
genuine benefi t to patients will always carry some
degree of risk. Even when used correctly, medicines
can be associated with adverse outcomes.
 Terminology
Adverse drug events, adverse drug reactions and medication
errors have been defi ned in a variety of different ways. Some of
the more commonly used defi nitions are shown in Box 4.1.
An adverse drug event (ADE) refers to an injury caused by
medication, such as gastrointestinal bleeding caused by
nonsteroidal anti-infl ammatory drugs (NSAIDs).
Adverse drug reactions (ADRs) form a subset of ADEs that occur at
recommended drug dosages. They are often categorized into two
broad groups – those that can be predicted from knowledge of the
drug’s pharmacological effects on the body (Type A) and those
that are unpredictable, idiosyncratic reactions that occur in
particular individuals (Type B). Type A reactions are more common
than Type B, accounting for over 80% of all reactions.
Specific examples of ADRs include allergic reactions to aspirin
when the allergy was unknown, or hair loss following a course of
cancer chemotherapy. By contrast, medication errors may occur
from the initial decision to prescribe to the fi nal administration of
the medicine, and these include selection of the wrong medicine,
dose, route and frequency or time of administration.
 Terminology
Figure 4.1 shows the relationship between ADEs, ADRs and
medication errors.
The relative sizes of each category will depend on the actual
rate of ADEs and medication errors within any healthcare
setting.
ADEs may or may not result from medication errors – for
example, an allergic reaction to flucloxacillin in a patient
without a known history of penicillin allergy is not the result
of a medication error, whereas a medication error has
occurred if the patient had a prior history of penicillin
allergy.
By definition, medication errors are preventable. Where the
error is recognized the situation can be retrieved (i.e.
administration stopped) and no injury to the patient may
occur; moreover, sometimes patients suffer no adverse
consequences from receiving the wrong medication.
Nature and extent of threats to patient safety associated
with medication in primary and secondary care

Inadequate drug and patient knowledge and lack of timely

Commplications arising from the use of medicines constitute access to information have been identified as important root
one of the most common causes of adverse events in causes of medication errors. Other risk factors include the
healthcare. work environment, workload, illegible prescriptions, poor
Within four weeks of receiving a prescription in primary communication and poor history taking. Organizational
care, 25% of patients experience an ADE, 11% of which are factors include inadequate training and low perceived
judged preventable. importance of risks associated with medicines.
Approximately 5% of all hospital admissions are associated With long-term drug therapy, the most appropriate drug
with ADRs, with higher prevalence rates (11%) reported in may be chosen and prescribed in the correct dose,
studies of elderly patients. frequency and duration.
While in hospital, the oral drug administration error rate is However, one of the commonest causes of adverse
approximately 5% of all doses due. The preparation and outcomes is failure to monitor. Repeat prescribing has been
administra_x0002_tion of intravenous drugs is also identifi ed as an important source of error, especially in the
inherently risky absence of standard operating procedures. A study in PH
general practice found that for 72% of repeat drugs
prescribed, there was no evidence of a review by a doctor
within the previous 15 months.
Reason proposed the ‘Swiss cheese model’ to illustrate how accidents can occur within systems. This analogy
compares the defensive layers of the system to layers of Swiss cheese, each having holes that represent safety
failures. The presence of holes in one slice may not result in an adverse event, because the other slices act as
safeguards.
However, the holes in the layers may temporarily line up, creating an opportunity for an accident. Figure 4.2 shows
how multiple failures in the drug use process can result in patient harm (Figure 4.3).
Residential and nursing homes and transfer
between settings
Medication errors may also arise when patients are transferred from primary care
(own home, residential or nursing care) to secondary care. On average, two
medication errors occur each time a patient is transferred from primary care, the
most common error being inadvertent withdrawal of drugs. In contrast, when
patients leave the hospital the most common problem is erroneous addition of
drugs.
One of the most recent studies in long-term care facilities suggest_x0002_ed that
ADEs occur at the rate of approximately 9 per 100 resident months, half of which
were judged to be preventable. More serious adverse events were also likely to be
predictable. Drugs most com_x0002_monly implicated include warfarin,
antipsychotics, loop diuretics, opioids, antiplatelets and angiotensin-converting
enzyme (ACE) inhibitors. The most frequent typesof ADE were neuropsychiatric,
haemorrhagic, renal/electrolyte and gastrointestinal problems.
 How can threats to patient safety associated
with the use of medication be reduced?
There are no easy solutions but there are some important • Patient education. Discussion with patients will often
approaches. identify their ideas about starting medication – they may not
expect a drug. Patients should be encouraged to take an
The main areas to consider are: active part in reducing drug errors, such as reading patient
• The decision to prescribe. A key issue in any prescribing information leaflets in the packaging.
decision is to balance possible risks and benefi ts. It may be • Improvements to the design of medicine packaging could
that the safest option is not to prescribe or that further help improve medication errors. It is estimated that a third
information is obtained about the drug or the patient. This of medi_x0002_cation errors are caused by confusion over
includes considerations about the drug (such as cautions, packaging and labelling instructions.
contraindications, interactions and side effects) or about the
patient (such as age, sex, presence of other diseases and
allergies) (Box 4.3).
• Medication reviews and monitoring. Long-term
medication should be reviewed because circumstances often
change, such as the addition of further drugs or the
development of new [Link] prescribing reviews
are essential, especially in the elderly. The exact frequency
of these reviews will depend on the drug being prescribed
and the condition of the patient, both medical and social.
 Role of the pharmacist in reducing threats
to patient safety associated with the use
of medication

Pharmacists have traditionally played an important quality control role in checking patients’
medication. These result from a variety of reasons that refl ect shortcomings in the basic rules of
safe prescribing, such as selecting he wrong drug, dose, quantity or strength of medication, with
higher error rates detected on handwritten prescriptions.
Likewise, hospital pharmacists detect errors in around 1.5% of prescription items. The majority of
errors (54%) are associated with the drug dose, and most serious errors originate in the prescribing
decision. Not surprisingly, both the experience of the pharmacist and the time that they spend on
the hospital ward have been shown to be significant predictors of an increased error detection rate.
 Role of information technology (IT)
Computing systems already exist that can link
patient history, laboratory results and
prescribing data and present a hierarchy of
warnings to inform, advise and, in specifi c
circumstances, prohibit the prescribing of
medicines (Box 4.5). In the USA, research has
shown that the use of computerized physician
order entry and decision support systems can
substantially reduce the incidence of serious
medication errors.
Despite this, the adoption of IT initiatives to
reduce risk associated with medicines has been
limited. To date, studies have generally been
conducted in specialized settings and rarely in
primary care where the vast majority of
prescribing takes place.
IV. Communication and Patient Safety

Communication is an essential part of the practice of

medicine. It is also essential for patient safety.

Communication is frequently a cause of, and a resource to

prevent, threats to patient safety.

The main areas for attention are communication with

patients, within healthcare teams and across the various
interfaces that occur within healthcare (Box 5.1).
Analysis of available data, from both
secondary and primary care, reveals that
only one in eight patients claim against
‘negligent doctors, and it is not dependent
on the level of technical expertise.
The decision to make a claim appears to be
related to how well the doctor had
communicated with the patient and
relatives, including explanation about the
risks associated with investigation and
treatment. If an adverse event does occur,
effective communication can also reduce
the likelihood of complaints and litigation
(Box 5.2 and Table 5.1).
Communication problems and the patient
Research has highlighted the importance of communication, both verbal and nonverbal, to increase patient satisfaction with
the consultation and compliance with the proposed management plan.
This will also improve patient safety and reduce the likelihood of a complaint being made against the doctor. Longer
consultations are associated with lower risk of malpractice claims, but it is important that the longer time is spent on effective
communication.
Communication problems are more likely when the doctor is in a hurry, angry or under stress. These are also the times when
there is increased risk of adverse [Link] is essential to establish a relationship with the patient.
Health Care Providers should appear friendly, be polite and show that they are giving attention to their patient by allowing
the patient to talk about their concerns. There is evidence that an unsatisfactory relationship can lead to the patient not
giving sufficient information, and this can lead to problems with diagnosis and treatment.
The patient will often attend because of anxiety about their condition and with clear expectations about how it will be
managed.
The doctor should try to identify and understand the perspective of the patient. This can be diffi cult in patients with
communication diffi culties or where there are differences in social and cultural backgrounds.
Agreement about the presenting problem and its management plan has to be achieved. This requires sharing of information
and negotiation. Common problems are the use of medical jargon and the lack of agreement by the patient about the
management plan, especially if they do not understand what they have been told.
It is essential to check patient understanding before the end of the consultation, including the arrangements for follow-up
and when to seek help if the condition does not resolve or worsens (Boxes 5.3–5.6).
Communication problems and the patient
Communication problems and the patient
Communication about the risks of investigation
and treatment
All healthcare interventions, whether for investigation or for treatment, carry a risk to
the well-being of the patient. The assessment of risks by patients is primarily
determined not by the facts but by the patients’ emotions. Many complaints are made
because the patient feels that the doctor was uncaring and that the risks were not
explained so that the patient could understand them and make an informed decision.
There is now a substantial literature on how to communicate risk most effectively to
give the patient greater satisfaction and certainty about making the best choice.
Patients dislike descriptive terms, such as ‘low risk’, because it refl ects the opinion of
the doctor. The use of absolute numbers, combined with the presentation of both
positive and negative outcomes, is preferred.
Throughout the process of communicating risk it is important to be honest about what
is known, and not known, and to explore people’s understanding, reactions and
opinions about the information that they are given.
 Communication problems and teams
Communication within healthcare teams is mainly verbal but can also
be written, such as the use of notes, message books and e-mail.
Research in high-risk industries, such as aviation and petrochemicals,
has highlighted the importance of communication to improve safety.
Good communication in the team is essential, but the skills also
include development of collective responsibility, resolution of
differences between staff, and empowerment to speak out about
observed problems in the safe operation of the various processes (Fig.
5.1).
Airline staff are trained in techniques such as ‘crew resource
management’, and similar approaches have started to be adopted for
members of resuscitation and operating theatre teams.
A ‘culture’ of disruptive communication can develop, especially
in hospitals, when the team is under stress and is constantly
hurried. This culture of high emotional expression can lead to
threats to patient safety.
A useful structure to employ when nurses, doctors or any
member of the clinical team need to communicate about a
patient’s condition is SBAR –Situation, Background,
Assessment and Recommendation ( Box 5.7).
V. Patient Safety Culture
All organizations have a culture – ‘how things are done around
here’.
The organizational culture is often immediately apparent when
an organization is encountered. For example, step inside any
outpatient clinic and you will immediately receive an
impression. Is it friendly? Are staff fraught?

The culture comprises the shared attitudes, beliefs, values and

assumptions that underlie how people within the organization
The shared beliefs and values of the people who go about their tasks. The same concept also applies to patient
work within the organisation. safety.
This influences the way that people act in the
organisation.
 Organizational safety culture
Research into high reliability organizations (HRO), • A prevailing attitude of chronic unease about potential safety
which experience fewer accidents than expected, threats. There are formal rules and procedures but the
such as aircraft carriers and nuclear power plants, has purpose
highlighted the importance of a culture of safety. is to create ‘heedful attention’ to high-risk situations instead of
Safety is the number one priority for the organization routine compliance. There is usually one individual who takes
and for each of the workers that work within that an overall (executive) view of the situation and monitors the
organization. response to the situation.
• Training is a high priority. This includes clear required
These organizations have several features:
competencies that are regularly assessed, often by
• High degree of autonomy but also interdependence. participating in simulations.
Individuals are empowered to act as independent • A collaborative structure takes over in situations of high risk.
operators but rely on others to perform tasks. In high-risk situations, the formal hierarchical relationships
• Multiple cultures and teams that work dis_x0002_sipate, all team members increase situational
interdependently. In_x0002_dividuals work as part of awareness, and each individual constantly monitors both the
cohesive teams, such as doctors or nurses, but also situation and the actions of other team members. Feedback on
rely on other teams to achieve complex tasks performance is freely given and received. The overall aim is to
effectively. maintain safety.
 Organizational safety culture
Patient safety is as much about behaviour, values and attitudes as it is about physical action (Box 6.1).
 The barriers to high reliability
organizations in healthcare
A major barrier is blame apportioned to individuals for any Division of labour
adverse event. This is particularly common in healthcare,
where there is a culture of high individual responsibility and Healthcare is complex and requires a differentiation of
where an error can lead to disciplinary or litigation professional roles, such as doctors, nurses or social workers. The
proceedings. The response is that individuals tend to deny more complex the process, and the larger the organization, the
the possibility of error and are not willing to disclose
greater the need for more healthcare workers of different types.
adverse events because of the fear of possible
recrimination. This inevitably creates diffi culties, with greater potential for
errors to occur, because of the requirement to coordinate,
The organization is often concerned with the wrong type of collaborate and cooperate. Most healthcare workers have had
excellence. There may be management goals that are in different and separate training, and often hold a value system
pursuit of efficiency, cost savings or patient satisfaction,
that is specifi c to their professional group.
such as pleasant décor.
The consequence is that patient safety is not expressed as a Diffusion of responsibility
high priority. Sociological studies of healthcare organizations
have highlighted two further important issues that hinder The problem of ‘too many hands’ involved inhealthcare,
the achievement of organizational goals and the
especially when it is complex, results in a collective lack of
maintenance of patient safety: division of labour and
diffusion of responsibility. responsibility for safety and little personalresponsibility and
feeling of accountability when adverse events occur.
 Assessment of patient safety culture
An essential first step in the process of improving
organizational culture is to assess its current state.
There are only a few tools available, and few have been
developed specifically for healthcare, especially primary
care. One such tool is the Manchester Patient Safety
Framework, which has been adapted in collaboration
with the National Patient Safety Agency (NPSA) for
acute, mental health and ambulance settings. It is likely
that further or refi ned tools will be developed in the
future.
Most tools have two types of statement to represent
the main safety culture dimensions – statements
relating to values, beliefs and attitudes, and statements
relating to behaviours that aim to improve safety, such
as leadership, policies and procedures. These aspects
are identified by the use of self-completed
questionnaires (Box 6.2).
 Developing a patient safety culture
An important first step is to ensure that patient safety
is high on the list of priorities for the healthcare
organization, and this needs to be coupled with a
clear executive responsibility, not only at the top but
also at each level of the organization, including each
clinical team (Box 6.3).
Cultural change is concerned with how people feel
and think about issues. Opportunities have to be
created for people to freely state their opinions, and
this openness then needs to be transferred to
systems that allow all individuals to report and
discuss adverse events. A ‘no blame’ culture gives
individuals an opportunity to disclose and discuss
without fear of punishment, but it does not absolve
individuals from being accountable for their actions.
An important aspect of developing a safety culture is
to ensure that each individual regards themself as
being personally, and collectively, responsible for
safety. Safety is everyone’s concern.
 Executive walk rounds (EWRs)

Executive walk rounds (EWRs) are a widely

used activity designed to improve safety culture
in hospitals. A recent study concluded that
EWRs have a positive effect on the safety
climate attitudes of nurses who participate in
the sessions. EWRs are a promising tool to
improve the safety climate and the broader
construct of safety culture (Box 6.4).
 Crew resource management approaches
The investigation of several major aviation The main aspects are:
accidents showed that cockpit errors • Situational awareness. This requires constant awareness
occurred despite various procedures that of the various factors – operational, technical and human –
were thought to increase safety, such as the that affect safe operation. Individuals increase their
awareness that under certain conditions error is more
use of checklists. The main factor associated likely to occur, such as a delay in commencement of a
with these accidents was inadequate procedure, working in a different environment, or when
communication between crew members, there is undue stress in any member of the team. The
especially related to situational awareness, result is increased vigilance.
with the result that there was a breakdown in • Planning and decision-making. Roles are clearly defi ned
the possible organizational defences. and the respective areas of responsibility are identifi ed.
Crew resource management is not concerned Potential high-risk situations are rehearsed.
with the technical skills but concentrates on • Communication. Effective communication between
the important cognitive and interpersonal team members is essential. This not only includes making
clear and unambiguous messages but also recognizes that
skills required for safe operation. making and receiving messages is dependent on a
willingness to make the action.
THE END. THANK YOU