Developing a Wider Range of Safety Strategies
The dominant vision of safety improvement is to increase the reliability of basic procedures. These might be the standard procedures in operating theatres, the prevention of venous thromboembolism or procedures to minimise central line or other infections. A number of major interventions have shown that with sufficient will, a sophisticated approach to implementation and the necessary resources, reliability can be markedly improved in a least a set of core processes.
We still have very limited safety strategies for dealing with the day to day realities of healthcare. The dangers to patients when staff are working in difficult conditions are sometimes discussed though generally in terms of the need for more staff which may, of course, be a reasonable request; if more staff were available, or their time was better used, then it might be possible to meet core standards. However in healthcare we will never be able to meet basic standards all the time and in all contexts. We need therefore to relinquish the hope that we will ever be able to do this in all circumstances and pose a different question. How can we ensure that care is safe, even if not ideal, when working conditions are difficult? How, for instance, should one manage an emergency department at times of very high workload or during major emergencies when the care of some less seriously ill patients is inevitably delayed or compromised. What strategies are available to a young nurse of doctor faced with an absurd workload, multiple competing demands and many sick patients? People do adapt and cope of course, but on an individual basis rather than with a considered team based strategy. Developing considered approaches to the management of risk in such situations is a priority for the next phase of patient safety (Box 11.4).
Box 11.4. Developing a Wider Range of Safety Strategies
• We should extend our safety strategies to include risk control, monitoring and adaptation, and mitigation
• We must not be ashamed to propose strategies that aim to manage risk rather than optimise care as long as the final result is beneficial to the patient and robust to context.
• Developing and implementing considered team based responses to difficult working conditions will be safer than relying on ad hoc improvisation
• Healthcare uses a very limited set of safety interventions. The limited progress in patient safety is partly due to the underuse of the available strategies and interventions. It is like driving a car and only using first gear.
We also need to consider how best to customise specific safety interventions. For example reviews of studies of interventions to reduce falls have provided conflicting evidence of effectiveness – some studies showed strong effects, others none. Frances Healey and colleagues argued that the conflict is only apparent and due to the fact that two very different kinds of interventions have been tested; some trials adopted a one size-fits-all implementation of a set bundle of procedures while others, in contrast, developed an individualized approach to each patient with responsive care planning and post-fall review. The standard intervention has been shown in large randomized controlled trials to have little effect; the more personalized approach, which stresses an adaptive response to risk, is proving very much more effective. Healey comments that this 'makes complete sense in the context of falls risk being a complex combination of intrinsic and extrinsic factors and personal attitudes to risk, in an acute environment where physical condition and therefore falls risk factors are rapidly changing' (Healey et al. 2014 and personal communication 2015).