Archive | March, 2015

What are the important issues in patient safety?

18 Mar

by Professor Bryony Dean Franklin, Professor of Medication Safety, UCL School of Pharmacy and member of the NIHR Greater Manchester PSTRC Strategic Advisory Group

Venn diagram

What are the important issues in patient safety? I was wondering where to start: the important problems? the important solutions? the important research questions? These are all rather big questions, and somewhat inter-related, so I thought I’d go with two general reflections.

First of all, I am increasingly struck by the enormous challenge of seeing the whole system – just like the tale of the blind men and the elephant.  We (researchers, clinical staff and managers alike) all tend to focus on individual parts of the bigger system – the medication bit, the surgical bit, the hospital bit, the GP bit – whatever our focus may be.  This is often driven by necessity – we need to break things down into manageable chunks to create achievable objectives and to focus our expertise appropriately.  However there are two key problems with this approach. First, we risk shifting problems from one area to another.  An example might be the mid 2000s’ introduction of bedside lockers to store inpatients’ medication in hospitals, with the aim of supporting medication reconciliation on admission and speeding discharge. However this has created new problems for nurses who often have to work out which of the overflowing pile of medication boxes should be given to the patient at discharge.  We hear of patients given supplies of ward stock medication, discontinued medication, or even medication belonging to the patient who occupied the bed before them.  Second, there is the very real possibility that we make one very small part of the system work well, while the stages before and after it still function badly. Given that most processes are only as good as the weakest link, this is potentially wasted effort. Going back to the story of the blind men and the elephant, the Wikipedia entry for this explains how it is based on a group of blind men, each of whom feels a different part of the elephant. They then compare notes and learn that they are in complete disagreement. Various versions of the story then differ in how violent the conflict between the men becomes, and if and how the conflict among their perspectives is resolved.  And so too within patient safety, the challenge for us is how we resolve this in order to understand the entire ‘elephant’ and improve patient safety across the whole system. Since we are each only likely to be experts on one small part, this is likely to need collaboration and creation of a shared understanding with a wide range of relevant stakeholders – including patients and carers.

Second, we need to consider patients’ experiences of care as well as other measures of patient safety. The subjective sense of patients and carers have other the extent to which they ‘feel safe’ with their healthcare, and the possibly more objective ‘freedom from harm’ that healthcare professionals may focus on, are different. Both are important, but viewed as two circles within a Venn Diagram, I suspect there may be little overlap. Even if someone’s care is ‘safe’ from a medical perspective, if they feel unsafe, perhaps due to receiving conflicting information of poor communication, then the system is not safe from their perspective.

Two important issues in patient safety are therefore the challenge of seeing the whole system, and including the perspectives of patients and carers. As patients are often the only people who experience the whole healthcare system, focusing on their experiences and perspectives may be the key to addressing both challenges.