Five Safety Strategies

We outline five broad strategies (Box 6.1) each of which is associated with a family of interventions. The strategies are, we believe, applicable at all levels of the healthcare system from the frontline to regulation and governance of the system. Two of the strategies we discuss aim to optimise the care provided to the patient. The other approaches are focused on the management of risk and the avoidance of harm.

Box 6.1 Five Safety Strategies

Safety as best practice: aspire to standards – Reducing specific harms and improving clinical processes

Improving healthcare processes and system – Intervening to support individuals and teams, improve working conditions and organisational practices

Risk control – Placing restrictions on performance, demand or working conditions

Improving capacity for monitoring, adaptation and response. Mitigation – Planning for potential harm and recovery.

The first two strategies approaches aim, broadly speaking, to achieve safety by optimising care for the patient. In a sense safety and quality and equated; the aim is to provide care at levels 1 and 2. Within this general approach we distinguish focal safety programmes aimed at specific harms or specific clinical processes (Safety as best practice) and more general attempts to improve work systems and processes across a number of clinical settings (Improving the system). These approaches are well described in the patient safety literature and we will only briefly summarise the main features here as our primary purpose is to draw attention to other important and complementary approaches.

Optimisation of processes and systems is indeed optimal if it can be made to work. The difficulty is that in the real world optimal care is usually not achievable for at least some of the time. Once there is evidence of a substantial departure from best practice then the question becomes how best to manage those departures and the associated risk. The remaining three approaches are risk management strategies: risk control; monitoring, adaptation and response; and mitigation. Optimisation strategies improve efficiency and other aspects of quality as much as they improve safety. In contrast risk control, adaptation and recovery strategies are most concerned with improving safety.

Safety problems are also sometimes resolved because of the introduction of a completely new way of investigating or treating an illness. The development and rapid adoption of laparoscopic surgery for instance means that patients no longer have large wounds from major incisions, are less vulnerable to infections and have a much shorter hospital stay. Reduction of infection is a major safety target but was here achieved indirectly by a major surgical innovation. While we recognise that innovation often improves safety we do not consider it as a safety strategy, in the sense of a plan that can be implemented relatively quickly, because major innovations usually occur over long time periods and can only be implemented once they have been tried and tested.

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