Patient safety revisited: changing the culture

Delivering safe patient care is fundamental in healthcare – no one could possibly argue that it is not a central tenet of what we do. However, it is also true that, repeatedly, we fail both ourselves and our patients by not managing care effectively; causing harm to our patients. The nature and scale of this harm is hard to comprehend. It is made up, worldwide, of hundreds of thousands of individual tragedies every year – in which patients are traumatised, suffer unnecessary pain, are left disabled or die. Many more people have their care interrupted or delayed by minor errors and problems; these incidents are not as serious for patients but are a massive and relentless drain on scarce healthcare resources.1 It is true that, in the last ten years, patient safety has become an issue which has come to the fore and is no longer a hidden topic that is not discussed or acknowledged by healthcare professionals. It is also true that patient safety has been the reason for a great deal of excellent work by professionals and continuing improvement in systems within care delivery. There remains, however, a great deal more that can be done. Many of the incidents reported to the National Reporting and Learning Service (NRLS) show that incidents are often caused by multiple factors, including failures in attention, memory, decision making and prioritisation. These failures are made more likely, or have more serious effects, if the system in which we work is flawed. It is also critical, according to Vincent et al,2 that we develop systems of measurement in patient safety that do not rely on voluntary reporting schemes such as NRLS. They make the comparison of surveillance systems for healthcareassociated infections (HCAI), which, when they moved from voluntary to mandatory, became an integral part of local reporting systems at board level, and thus became the focus of attention at the highest levels within hospitals. It was only then that raised awareness enabled resources to be focused on training, learning from events and reviews of local failures that changed management and clinical systems which affected patients; reducing HCAI incidents and levels of harm to patients.

Patient safety dimensions of quality

The dimensions of quality, as defined by the Institute of Medicine3, are worth considering as they are clear, unequivocal and comprehensive (Table 1). Many authors writing about patient safety recognise the inherent complexity of healthcare. However, one factor which can only add to the commitment to improve quality and safety in our systems is that airline passengers can expect a safety ratio of 1:10,000,000, whereas hospital safety for patients is 1:300.4 This indicates to the author that while many efforts are being made, they are simply not yet focused on the dimensions of quality and nor do they have the attention (and therefore the resources) of hospital boards. The Health Foundation5 reviewed numerous research articles to try to identify whether the body of current evidence could link a hospital’s (or group of hospitals’) culture of safety to outcomes either for patients or for staff. They discovered mixed results and of particular interest is that few empirical research papers sought to identify a link between safety culture and outcomes for patients. A small number of studies that were examined found a relationship between safety culture and hospital morbidity, adverse events and readmission rates, but others found no impact on patient outcomes. They found more evidence that improving safety culture impacts on staff safety behaviours and injury rates among staff. They also report that some studies have found simultaneous improvements in the safety culture and patient outcomes following improvement initiatives.