The Advent of Professionalism 2002–2005

In the late 1990s, James Reason provided an inspirational vision for healthcare that provided a clear demarcation between traditional approaches to quality improvement and the specific problems that arise when addressing safety (Reason 1997; Reason et al. 2001). Safety researchers, clinicians and managers took the concepts, techniques and methods from industrial safety and applied them to healthcare. These included a stronger emphasis on the role of latent organisational conditions which led to the development of methods of incident analysis derived this model (Vincent et al. 1998, 2000). Increasing attention was also given to human factors and ergonomics, following the success in improving interface and equipment design in industry, the use of information technology and a scientific approach to working conditions, stress and fatigue management (Bates 2000; Sexton et al. 2000; Carayon 2006). Accreditation and certification built on this new knowledge in requiring hospitals to establish risk management programmes and new patient safety indicators. Safety and risk management acquired a much higher profile and many new initiatives were developed across the healthcare system, but the impact on the safety of patients remained uncertain (Pronovost et al. 2006; Wachter 2010). The lack of clinical engagement was a major concern with patient safety remaining the province of enthusiasts and specialists – a curious situation given that safety, considered in terms of personal accountability, is perhaps the dominant concern of clinicians in their day-to-day work with patients.

Safety Culture, Multifaceted Interventions, and Teamwork 2005–2011

Surveys of safety culture demonstrated unequivocally that in many hospitals and other healthcare settings safety attitudes and values were far from ideal. Findings from many studies suggested an excessive blame culture, pressure on performance

to the detriment of safety, little transparency towards patients and variable levels of supervision and teamwork. There was also huge variability between hospitals, within clinical disciplines and across different settings (Tsai et al. 2013). Whereas safety culture was initially seen as potentially directly impacting on safety, there was now a growing awareness that it might provide only a necessary foundation (Flin et al. 2006; Vincent et al. 2010)

However, as we have discussed, evidence began to emerge of marked improvements in specific safety problems at a local level and of the potential of wider application of approaches such as checklists, care bundles and so on (Haynes et al. 2009; Shekelle et al. 2011). Those proven safety wins on the frontline encouraged the healthcare community to believe that safety would progressively improve as more interventions were put into place. Improving safety across organisations and populations however has proved a great deal more challenging. The major difference between current views and what was imagined in the mid 2000s is that safety wins and rewards are now expected in the middle to long term rather than in the very short term.

Reflections on Safety in Hospitals

We provide this brief overview primarily to highlight the fact that approaches to safety in hospitals have primarily been optimising approaches of one kind and another, although comparatively little attention has been given to optimising the system overall as opposed to improving specific practices. Accreditation and regulations of the system might be thought to be examples of risk control and there are certainly examples of standards being set in order to minimise or avoid risks of certain kinds. However we suggest that most accreditation and regulation is essentially aimed at assessing compliance or failure to comply with defined standards of care. Regulators are sometimes forced to acknowledge that standards cannot be met and that adaptations must be made but we suggest that the dominant vision of how safety is achieved is one of adherence to standards.

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