Monitoring, Adaptation and Response

We have repeatedly emphasised that failures and departures from standards are not the exception but the day to day reality of healthcare. Safety is achieved partly by attempting to reduce and control such failures but also, in recognition of the impossibility of this task, by actively monitoring and managing problems that arise. The critical question is whether we leave this to ad hoc improvisation or try to build this capacity into the system (Vincent et al. 2013). Many proposed safety initiatives fall into this category but few have been implemented in a thoroughgoing and strategic manner. We provide some a small number of examples but there is huge scope for the development, formalisation, training and implementation of considered approaches to monitoring and adaptation.

Patients and Families as Problem Detectors

The active engagement and empowerment of patients and carers in an increasingly complex system poses huge challenges on many fronts. Patients and carers will have an increasingly important role in maintaining safety as home care expands, which will be discussed in the following chapter. At this point we simply want to highlight that almost all safety interventions that are aimed at patients fall into the category of monitoring, adaptation and response. In the hospital context patients and carers are in many cases being asked to compensate for problems of poor reliability and to form an additional defence against potential harm (Davis et al. 2011).

Many patient focused safety interventions are aimed at encouraging people to speak up if they notice problems with medicines, identification or other issues. More challengingly patients are asked to confront staff who have not washed their hands to support infection control (Pittet et al. 2011). Some of these interventions are entirely reasonable and in fact necessary; patients have a privileged and unique view of their own care and we need their insights into how safety is compromised. But we should be clear that patients are often being asked not only to check for problems that arise in complex care but to detect and compensate for problems that are not of their making.

Team Training in Monitoring, Adapting and Response

Teams, when working well, have the possibility of being safer than any one individual because a team can create additional defences against error by monitoring, double-checking and backing each other up: when one is struggling, another assists; when one makes an error, another picks it up (Vincent et al. 2010). Several authors have described how healthcare teams in emergency departments (Wears and Woods 2007) and operating theatres (Carthey et al. 2003) anticipate and thwart potential safety events. This can extend to more formal collaborative cross-checking, where one person, role, group or unit provides feedback about the viability or possible gaps in another's plans, decisions, or activities (Patterson et al. 2007). Allied to this is the development of a safety culture in which speaking openly about error is supported and indeed encouraged. Once one realises that errors and failures are inevitable, at least when the system is under pressure, the rationale for openness about error becomes clear. This kind of preparation is particularly critical in the more fluid and dynamic clinical environments where uncertainty is common and lapses frequent. For example, the WHO Surgical Safety Checklist is usually thought of as a means of checking processes such as the giving antibiotics in a timely fashion. However the checklist also prompts a brief period of reflection (the 'time out') in which members of the theatre team highlight potential problems and, by introducing each other, increases the chance of team members speaking up if problems are identified (Haynes et al. 2009; Kolbe et al. 2012).

Briefings and Debriefings, Handovers and Ward Rounds

Operational meetings, handovers, ward rounds and meetings with patients and carers are all sources of intelligence that allow the monitoring of safety For example, operational meetings held by senior managers can unblock beds and improve the flow of patients through a hospital, identify safety issues relating to infection outbreaks, and thwart the potential for unsafe discharge of patients. Briefings carried out by operating theatre teams provide an opportunity to identify and resolve equipment problems, staffing and theatre list order issues before a case starts. Debriefings carried out at the end of the theatre list support reflective learning on what went well and what could be done better tomorrow. Increasingly, briefings and debriefings are being introduced in other healthcare domains such mental health teams (Campbell et al. 2014).

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