Our Model of Intervention Is Limited
The most dramatic safety improvements so far demonstrated have been those with a strong focus on a core clinical issue and a relatively narrow timescale. These interventions, such as the surgical safety checklist and the control of central line infections, are of course far from simple in the sense that they have only succeeded because of a sophisticated approach to clinical engagement and implementation. More general system improvements may extend to an entire patient pathway. For instance the introduction of the SURPASS system using checklists and other improvements to communication along the entire surgical pathway and showed a reduction in surgery complications (de Vries et al. 2010). Bar coding and other systems have massively enhanced the reliability of blood transfusion systems, incrementally improving each step of the pathway (Murphy et al. 2013).
We should however be wary of modelling all future safety interventions on our most visible successes. At the moment the primary focus is on developing interventions to address specific harms or to improve reliability at specific points in a care process. This, entirely reasonable, approach is evolving to include the reliability of entire care pathways or areas of care (such as an out-patient clinic). We will argue however that, in addition to increasing reliability, we also need to develop proactive strategies to manage risk on an ongoing basis, particularly in less controlled environments. There is also a class of strategies and interventions, particularly those that focus on detecting and responding to deviations, that are particularly critical for preventing harm to patients. These approaches do not feature as strongly in the classical quality and safety armament.
We also need to recognise that safety, for any person or organisation, is always only one of a number of objectives. For instance, many sports involve an element of risk and potential harm. When we become patients we necessarily accept the risks of healthcare in pursuit of other benefits. Similarly a healthcare organisation can never treat safety as the sole objective, even if they say safety is their 'top priority'. Of necessity, safety is always only one consideration in a broader endeavour, whether in healthcare or in any other field. As an oil executive expressed it: 'Safety is not our top priority. Getting oil out of the ground is our priority. However, when safety and productivity conflict, then safety takes precedence' (Vincent 2010). Similarly, in healthcare, the main objective is providing healthcare to large numbers of people at a reasonable cost, but this needs to be done as safely as possible.