Managing Risk in the Real World

We have put forward a series of arguments culminating in the idea that patient safety should be viewed as the management of risk over time. We have suggested that healthcare could draw on a much wider repertoire of strategies and interventions to manage risk and enhance safety. This has been a book of ideas and argument but we hope that these are both rooted in practice and have practical application. In this chapter we first consider some of the more immediate implications as we see them and then consider the form a longer term exploration and development might take.

Implications for Patients, Carers and Families

The engagement of patients in patient safety has been a slow and difficult process. Much of the initial effort has gone into engaging patients alongside staff in reporting and acting on safety issues. This has been a valuable exercise but there is always (rightly) going to be a limit on what it is reasonable or feasible for patients to take on in hospital. We should now turn our attention to the home and community which will pose very different safety challenges. For instance, nosocomial infections are common in hospitals but we have developed effective ways of countering them which rely on close monitoring and a rapid clinical and organisational response. In the home, the risk of nosocomial infections may be less but other risks arise from the open environment, frequent visitors and varying standards of hygiene. Safety is a moving balance between accepted risks and available solutions; you can improve safety either by changing the exposure to risk or improving solutions.

In the home and community patients are in charge of care, and therefore responsible for safety, capable of making errors and being influenced by the many factors that affect safety. This is more than engagement, shared decision making or partnership. Patients and families are taking on roles and responsibilities that are in other settings restricted to professionals. This raises a host of issues for the management of risk and indeed for the delivery of services generally.

We know that patients and families take safety very seriously and are ingenious in managing many potentially dangerous scenarios. We have given examples in the book and no doubt many more could be collected and studied to reveal novel strategies and interventions which could be shared, adapted and potentially used more widely. Our five strategies can be used to pose some immediate questions about the risks managed by patients and families. What training should be given? If a professional needs training to, for instance, change a dressing while maintaining sterile conditions then surely patients and carers need training too. To what extent can standards of hygiene be relaxed simply because a sick person has moved from hospital to home? We may need to consider setting standards and controlling the environment in which care can be delivered. What kind of support do patients and families need if they are to monitor safety and act appropriately on signs of deterioration? The example of home haemodialysis given earlier shows that advanced units are now including a suite of safety strategies in their training for patients and families. This could potentially be replicated, in varying degrees of intensity, for other forms of care outside hospital.

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