Harm Has Been Defined Too Narrowly
We agree with those who seek to provide a more positive vision of safety (Hollnagel 2014). The punitive approach sometimes taken by governments, regulators and the media is, for the most part, deeply unfair and damaging. Healthcare while enormously beneficial is, like many other important industries, also inherently hazardous. Treating patients safely as well as effectively should be regarded as an achievement and celebrated.
We make no apologies however for continuing to focus on harm as the touchstone for patient safety and the motivation for our work. We will put up with errors and problems in our care, to some extent at least, as long as we do not come to harm and the overall benefits clearly outweigh any problems we may encounter. Many errors do not lead to harm and may even be necessary to the learning and maintenance of safety. Surgeons, for example, may make several minor errors during a procedure, none of which really compromise the patient's safety or the final outcome of the operation.
Patient safety, particularly the large scale studies of adverse events, has its origins in a medico-legal concept of harm. We have, for the most part, now separated the concept of harm from that of negligence which is an important achievement, though we still tend to think of safety as being the absence of specific harmful or potential harmful events (Runciman et al. 2009). Harm can also result from loss of opportunity due to a combination of poor care and poor coordination whether inside the hospital, at the transition with primary care, or over a long period of time in the community. Evidence is growing that many patients suffer harm, in the sense that their disease progresses untreated, through diagnostic error and delay (Graber 2013; Singh et al. 2014). In some contexts, this would simply be seen as poor quality care falling below the accepted standard. But for the patient a serious failure can lead to untreated or unrecognised disease and, from their perspective, to harm.
Box 1.1 Safety Words and Concepts
The term 'medical error' has been used in a variety of ways, often as shorthand for a poor outcome. We use the term error is in its everyday sense as a retrospective judgement that an action or omission by a person did not achieve the intended outcome. We use the term reliability when considering processes and systems rather than the actions of people.
The aims of the patient safety movement can be stated in a number of different ways:
• To reduce harm to patients, both physical and psychological
• To eliminate preventable harm
• To reduce medical error
• To improve reliability
• To achieve a safe system
All these are reasonable objectives but they are subtly different. We suggest that the central aim must be to prevent or at least reduce harm to patients, while acknowledging that the concept of harm is difficult to define and other objectives are also valid. As the book develops we will suggest that the most productive way to approach patient safety is to view it as the management of risk over time in order to maximise benefit and minimise harm to patients in the healthcare system.
We believe that the current focus on specific incidents and events is too narrow and that we need to think about harm much more broadly and within the overall context of the benefits of treatment. As the book evolves, we endeavour to develop a different vision which is more rooted in the experience of patients. As patients, the critical question for us is to weigh up the potential benefits against the potential harms which may, or may not, be preventable. While we certainly want to avoid harmful incidents, we are ultimately concerned with the longer term balance of benefit and harm that accrues over months or years or even over a lifetime.