Can we get to zero?

Influencing behaviour change, human factors and embedding safety culture were among the core themes explored at Infection Prevention 2014, with the aim of eliminating harm, preventing healthcare-associated infection and improving quality of care. Recent research suggests that levels of harm range from 3% to 25% in acute care (Health Foundation, 2011). Focusing on how to make care safer, Professor Jason Leitch, clinical director, The Quality Unit, Scottish Government, considered the question: “Can we get to zero?” He pointed out that traditional methods have long been deployed in the name of improving the quality of care given to patients, including education, audit, inspections and the production of guidance. But how can we provide reliable healthcare systems to ‘every patient, every time?’

He opened the session with a personal account of the varying quality of care that his grandmother had received at hospital, after he found her collapsed with a broken hip, following a stroke. At this time, he had been the national patient safety lead. On arrival at A&E with his grandmother, one of the attending doctors recognised him and took off his jacket (as he was about to leave), and stopped to attend to her. 

“He was very sympathetic and nice to her, but he put a cannula in her arm within seconds of her arrival, without washing his hands and without cleaning the skin... I was the clinical lead for patient safety and I didn’t stop him; I didn’t say a word,” he commented.