New Challenges for Patient Safety

The developments described in the previous chapters are required because our present vision of safety is not adequate for the challenges we face. Our arguments for these developments rest on analyses of the nature of safety in healthcare as it is delivered today. However, as is well known, healthcare is changing rapidly and there are many new opportunities, pressures and challenges. We believe that these coming changes will have further implications for how safety is understood and practiced which will increase the urgency and importance of the transition to a broader vision.

In this chapter we briefly summarise some of the recent and forthcoming developments in healthcare. These have been widely discussed and we are only concerned to summarise some key points. The primary purpose of the chapter is to consider the implications for patient safety and for the strategies and practices we set out in the remainder of the book.

The Changing Nature of Healthcare

The problems faced by healthcare, and many of the challenges for patient safety, arise in part from the very success of modern medicine in combating disease. Because of improvements in diet, nutrition, medicine and environment many people are living longer but also living with one or more chronic conditions such as diabetes, cardiovascular disease and cancer. Diseases which were once fatal are now becoming chronic conditions.

The survival rate for cancers, infections and AIDS, strokes, cardiovascular disease and many other previously fatal diseases have improved significantly even in the last decade. For instance a recent French study of 427,000 new adult cancer cases diagnosed between 1989 and 2004, showed significant improvements in 5 year survival for most cancers, especially prostate cancer (Grosclaude et al. 2013). In the French population of 65 million people over 320,000 new cancers are diagnosed every year; of these 150,000 are designated as 'cured' within the same year and a further 150,000 can expect to survive at least 5 years. Similar improvements in survival and quality of life in AIDS patients have been seen in developed countries with the introduction of HAART therapies (Highly Active Antiretroviral Therapy) (Borrell et al. 2006). Most people treated for chronic conditions are going back to work, family and home, with the personal ambition of leading as healthy life as possible. These developments present huge challenges for healthcare systems in providing care and yet remaining affordable.

The traditional hospital cannot remain the main provider of care and core of the medical system simply because it would be unaffordable. Hospitals are still of course essential in any future vision of healthcare but will increasingly focus on investigations and procedures that require a very high level of expertise and sophisticated technology. The proportion of beds devoted to high dependency and intensive care will increase while the overall number of beds will reduce (Ackroyd-Stolarz et al. 2011).

Medical innovations have lead progressively to shorter hospital stays. Earlier diagnosis and less invasive treatments, such as laparoscopic surgery, mean that treatment can be instituted earlier and with less disruption to a person's life. Genomics and preventive medicine will potentially allow even earlier diagnosis and preventative treatment. Increasingly care will need to move outside the hospital which will require a very different vision of primary care. Hospitals specialists will move outside the hospital taking their expertise to homes and to other facilities (Jackson et al. 2013). Because of the growth of point of care testing and the refinement of many treatments, it will be possible to provide a considerable amount of care in community settings. Surgery, radiotherapy, chemotherapy and haemodialysis can all potentially be provided in out-patient settings or smaller community centres.

Box 10.1. A Summary of the Healthcare Paradigm Shift Needed for the Future



One size fits all


Personalized medicine

Fragmented, One-way


Integrated, two ways

Provider centred


Patient centred



Shift to community



Less invasive, image-based



Episode-based, Outcome-Based

Treating sickness


Preventing sickness“Wellness”

Adapted from (

The changes outlined above have profound implications for all health professionals (Box 10.1). Over the last 50 years hospital based medical specialties have been dominant in terms of status, reward and expertise. Specialisation has brought the greatest rewards although this has led to a loss of generalist skills and the ability to deal with the complex co-morbidities of care of older patients (Wachter and Goldman 2002). The need for traditional surgery is declining because of the availability of less invasive interventions carried out by radiologists, gastroenterologists and cardiologists. The role of the doctor is also changing rapidly as more care can be given by nurses and other professionals leaving the doctor in a more supervisory capacity and as the arbiter of complex decisions.

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