Safety Strategies in Hospitals

We have developed a series of ideas and proposals in the book which together laid the foundations for five safety strategies described in Chap. 6. We believe that thinking of safety strategies in this way has three major advantages: first, we can enlarge the range of safety strategies and interventions available to us; secondly we can customise the blend of strategies to different contexts and third the high level architecture of safety strategies may help us think more strategically about safety both day to day and on a long term basis

In this chapter we begin the process of exploring how these strategies might support safety in the hospital. The following chapters address home care and primary care. In each case we provide a short introduction to relevant aspects of safety in each context but do not dwell on well-established findings. Our primary purpose is to provide examples of interventions associated with each of the five strategies and to give a sense of the potential value of such an approach. We recognise that, in the longer term, considerable further empirical work would be needed to develop and confirm (or discount) our proposals.

A Little History

Hospital care has been the main focus of patient safety for two decades now and we can distinguish a series of phases of exploration and intervention. Each phase brought some success but simultaneously revealed barriers and limitations, which in turn stimulated a new phase of work in an evolving trial and error strategy. With experience and maturity, we understand more today about what is achievable and what has proved illusory. We are much more aware of how difficult it is to improve safety in both the short and long term.

What has been done in past decades? In the past 15 years we can distinguish three main phases each associated with different types of action and intervention. The earlier strategies have continued as the new ones emerged so that we now have 'a safety layer cake' of practices and interventions.

The Enthusiasm of the Early Years, 1995–2002

Systematic work on patient safety began in the mid 1990s with an emerging demarcation between a broad concern with quality and a specific focus on harm. In Britain for instance the development of clinical risk management, initially targeted at the reduction of litigation, brought a new emphasis on the analysis and reduction of harmful incidents and events (Vincent 1995). The methods and assumptions however remained rooted in those of quality improvement; the aim was to identify and count errors and incidents and then find ways of preventing them. Establishing reporting systems to detect and record incidents was at the core of the strategy. This approach was rapidly reconsidered as a result of both massive under-reporting, especially from doctors, and a gradual realisation of the impossibility of resolving the growing number of problems identified in reporting systems (Stanhope et al. 1999). A wider vision was needed which was provided by systemic concepts and tools imported from industry.

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