Friday, August 05, 2005

The patient safety story

A good review of patient safety and error ...

"Investigating and improving patient safety in health care is now an international phenomenon. The establishment of the National Patient Safety Agency in the United Kingdom1 and of the Center for Quality Improvement and Patient Safety in the United States2 are prime examples of the prominence given to safety within the wider concept of healthcare quality. No longer can there be any doubt that the most fundamental ethical principle in medicine—first, do no harm—is being taken seriously by a wide constituency. The next step is to embed safe practice into everyday clinical behaviour.

The catalyst came from the United States. By 1998 some opinion leaders in health care were frustrated by the lack of attention given to addressing serious quality challenges. An extensive review of the literature on quality, conducted by RAND Health, documented shortcomings in both safety and effectiveness.5 Expert panels, one convened by the Institute of Medicine and another established by the President of the United States, recommended that improving healthcare quality should become a national priority.6 7 But despite the strong, convincing evidence and recommendations from expert panels, the "quality problem" never made it on to the national agenda.

There are many lessons here. Firstly, targeting the public made the issue visible and widened the debate. Secondly, and just as important, was the clarity of the message. Errors are something that everyone can understand. People are familiar with "accidents" and efforts to avoid them. There are parallels in air and road transport; indeed in these services there are institutions to protect the public. Thirdly, the report focused primarily on errors of execution—events that no one intended to happen and where there is wide agreement that something went wrong."   continued ...   (Via BMJ)

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