Patient safety: a wake‐up call

Abstract

Purpose

The aim of this review is to examine factors that may explain why other industries are considered ultrasafe while progress toward preventing adverse events in health care is not considered to have reached that level.

Design/methodology/approach

The paper is a narrative review.

Findings

Despite a decade of intense effort, the problem of patient harm in health care facilities remains a challenge. A recent study of ten hospitals in North Carolina, which have actively engaged in patient safety initiatives, reported rates of adverse events similar to those in the Institute of Medicine report, To Err Is Human in 1999. Seven key issues and their interaction are described.

Research limitations/implications

This review focuses on broad issues that likely impede progress generally, not on individual project or individual hospital program success stories.

Originality/value

The authors believe the difficulty in making significant headway on the patient safety agenda is due in part to the fact that it was always going to be a long (indeed never ending) struggle – aviation for example took almost 60 years to become ultra‐safe – and in part to misunderstanding the nature of the dynamics that are involved in the generation of adverse events in risk critical industries. The paper reflects on the nature of the safety initiatives that health care has tended to focus on, but which have not sufficiently taken note of central concepts of safety science, as well as on features of the health care system itself that have impeded, in the authors' view, progress on enhancing patient safety.

Citation

Sheps, S.B. and Cardiff, K. (2011), "Patient safety: a wake‐up call", Clinical Governance: An International Journal, Vol. 16 No. 2, pp. 148-158. https://doi.org/10.1108/14777271111124509