Safety in Hospital: Distinguishing Current and Future Strategies

We propose that thinking in terms of an overall blend of high level safety strategies customised to different contexts will be an efficient and effective approach both to managing safety on a day to day basis and to improving safety over the long term. However before we start to illustrate how the five different strategies might be employed in hospital we need to consider a critical issue, which is that staff and organisations often have to employ a particular strategy not because of the needs of that clinical environment but to compensate for other underlying problems in the system. For instance, services such as acute medicine rely very heavily on monitoring, adaptation and recovery to observe, correct and recover from the inevitable departures from best practice and unforeseen problems that arise. However the fact that a strategy is extensively used does not necessarily mean that it is desirable; it might in fact be overused to compensate for other deficiencies such as poor reliability or inadequate staffing (Box 7.1). We therefore need to make a distinction at this point between:

• The blend of strategies currently used by an organisation

• The blend that might be desirable

• The strategies that might need to be developed or enhanced

Box 7.1. Adaptation and Compromise on the Wards

Recently while on call at the weekend I found my team looking dispirited, ploughing through 27 pages of printed jobs that were required for patients based on ten wards. There was no way these could all be done by two junior doctors. They were doing what any sensible person would do and “working round” an impossible task, rationing what was essential or urgent and what could be omitted.

A large proportion of the workload is phlebotomy, taking bloods and chasing the results. These should be taken by technicians but they have a fixed contract for 4 h meaning that they only deal with a small proportion of the overall workload. Tests are ordered by weekday teams, and handed over to the weekend team to check results, often without a clear indication of the purpose of the tests or what to do with the results. The weekend teams only become aware when blood has not been taken when they check for the result, leading to considerable delay in monitoring patients. There is huge variability in the clarity of the requests, the background information given, the appropriateness of the job itself and what to do with results, all compounded by the inexperience and insecurity of junior doctors on call at weekends.

Inada Kim (personal communication 2015)

Staff in all environments rely on workarounds such as obtaining information from patients rather than their health records, or using disposable gloves as tourniquets. In some cases, risks are taken such as making clinical decisions without information, or transferring used sharps to sharps bins in remote locations (Burnett et al. 2011). Often front-line coping and adaptation leads to short-term “fixes” that put off more fundamental, long-term solutions. These clinical work-arounds may also allow managers to protect themselves from inconvenient truths and shift accountability for failure to front-line workers (Wears and Vincent 2013).

We therefore always need to think, when formulating the overall approach to safety, both about what the approach is now and what might be the most effective strategy in the longer term. We certainly believe that adaptive strategies should be further developed in the sense of being planned and to some extent formalised. However this is very different from the current reliance on ad hoc improvising to compensate for missing information, faulty equipment and the like. Figure 7.1

Fig. 7.1 Improving systems reduces the need for adaptation

illustrates these ideas in the context of acute medicine suggesting that increasing reliability and controlling flow and demand would reduce the need for adaptation and improvisation. With this in mind we now illustrate the five safety strategies in the context of the hospital; we devote most space to risk control, adaptation and mitigation as the other two strategies are already well described.