A blueprint for safer clinical practice

In the first three articles of this series I set out the case that even the most skilled and diligent professionals can make mistakes. I then highlighted the most error provoking conditions. Effective well briefed teams can assist in trapping such errors before they become a patient safety issue. In this final instalment I will discuss clinical strategies to make life safer for patients and to improve the working environment for staff. Healthcare expenditure will experience increased scrutiny as the gap between provision and demand widens and front line staff will face growing pressure to become more efficient. Safety failures are always expensive and wasteful. Efficiency savings should be focused on avoiding this waste and must not be made at the expense of thoroughness or patient safety. While there is always a trade off between efficiency and thoroughness, an effective balance can be struck without damaging patient safety providing that teamwork practices are structured appropriately.1 A fundamental role of the leader of any clinical team must be to remain vigilant, both to eliminate waste and to ensure that resources are sufficient to deliver safe outcomes. If not then they and their team members must make the case for change. The principles in this article have already been set out in our paper, published in a recent edition of the Milbank Quarterly.2 My thanks go to my co-authors, in particular to Dr Geraint Lewis, who led the team of authors and gave his permission for extracts from the paper to be reproduced here. I spent 34 years as a commercial pilot, the last half of which was transformed when we, as an industry, understood the importance of “human factors”. If I had to choose which half of my career to undertake again it would definitely be that enlightened half! During the last 10 years I have been working in the field of human factors with healthcare professionals, particularly in surgical settings: the complexity and risk of modern surgery makes the contribution of human factors understanding to surgical safety even more important than it has been shown to be in aviation.

The key issue

Modern commercial aviation is extremely safe, with only one life lost per 10 million flights. Patients, particularly those in hospitals, do not fare as well: for every 100 to 300 patients admitted to hospital, there is at least one death caused inadvertently by a healthcare professional or medical procedure. The causes are multiple. Aviation’s safety record is not the result of good luck, chance or a single measure, but rather the outcome of numerous safety measures consistently applied to protect passengers and crew alike. Some of these safety concepts, adapted from aviation, have been successfully implemented in healthcare at low-cost. For example, the World Health Organization Surgical Safety Checklist has reduced deaths and surgical complications by more than one-third in some settings. The study, published in Milbank Quarterly, has identified 15 safety practices that are routinely used in aviation but are not yet applied in healthcare, and examines their suitability for this environment. We also consider potential resistance that might arise from physicians called upon to adopt these changes, and the potential cost benefits. Human factors safety measures used in aviation can be divided into three distinct categories: • Those intended to emphasise the importance of teams and organisations rather than to downplay the role of heroic individuals. • Those that will increase and apply group knowledge of safety information and values rather than consolidating existing practice. • Those that promote safety by monitoring performance and promoting redesign. Nine good examples of aviation safety measures that might be applied more widely in clinical care are: