Preventing avoidable harm: learning lessons

The Health Foundation is calling for a move away from an approach that largely looks at what can be learned when something goes wrong to one that looks at how it is possible to make sure whole systems go right in the first place, moving attention from measuring errors to designing for safety.

The extent to which healthcare can endanger patient safety is acknowledged worldwide.1 In the UK, a case note review published in the British Medical Journal in 2001 confirmed that 11.7% of admissions in two hospitals led to an adverse event.2 A 2010 report from the Health Foundation, How safe are clinical systems?, presented findings from research into the reliability of healthcare systems conducted by a team from Imperial College and Warwick Medical School. It focused on five key systems and processes – availability of information when making clinical decisions; prescribing; handover; availability of equipment in operating theatres; and the availability of equipment for inserting intravenous lines – in seven NHS organisations. This research found that the reliability of care pathways can vary even within the same organisation, with between 13% and 19% of care processes failing to be completed to the agreed standard every time.3 The Health Foundation concluded its 2010 report by saying that it believed it was no longer acceptable to treat the level of variation in reliability it had identified as being acceptable or inevitable. It set about looking for a way forward and subsequently published the report Using safety cases in industry and healthcare,4 which looks at research carried out by a team led by Warwick Medical School into the use of ‘safety cases’ in safety-critical industries and their potential application in healthcare. Safety cases were developed by the oil, nuclear and rail industries in response to high-profile accidents and other drivers such as the privatisation of the UK railways. They are built around an explicit agreement of the level of safety that is deemed acceptable. Staff collect evidence from a range of different sources to build a sound argument that systems are safe and risks are controlled and monitored. These arguments and their supporting evidence are called safety cases. Once risks have been identified, modifications can be put in place to ensure that those risks are reduced or eliminated and the system reliably delivers the expected levels of safety. Safety cases could provide a structured tool for showing that the local risks to clinical systems have been both identified and addressed.

Providing evidence