A recent report from the Health Foundation evaluates the findings of its six-year ‘Safer Clinical Systems’ programme which explored how improvements in healthcare quality could be made using techniques from hazardous industries.
It is a fact that patient safety problems exist throughout the NHS. However, it is often the systems, procedures, environment and constraints faced by healthcare professionals that lie at the root of safety problems and not staff negligence.
Healthcare providers often seek to control risks with incident reporting systems and risk registers to track the safety challenges that staff document. While generating huge amounts of data, these methods often yield an incomplete picture of the extent to which systems are safe and analysis tends to be based on reports of what has gone wrong in the past. Although this does play an important role in monitoring and measuring safety it may not be a good indicator of the next problem to arise or the underlying causes of harm.
Other hazardous industries such as aviation, mining and nuclear power have succeeded in reducing risk, and pay constant attention to further improvements in safety. This has been achieved by systematically understanding work processes and the risks associated with them, and then redesigning the processes with safety objectives in mind. Achieving these safety results has required sustained resources and focus at all levels over many years.
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