Rethinking Patient Safety

Rethinking Patient Safety, by Suzette Woodward, CRC Press 2017

                  In this life we cannot always do great things.  But we can do small things with great love.  Mother Teresa

Is healthcare safer?  Hard to say, but the author cites a pioneering Harvard Medical Practice Study based on research undertaken in 1984 to show how important patient safety was becoming.  The researchers studied 30,000 randomly selected discharge records from 51 New York hospitals in the United States.  They found that serious adverse events (harm related to the care provided and not to the illness or disease) occurred in 3.7% of the patients in their study.  Of the 3.7% adverse events, the researchers considered that 58% were attributable to error and deemed preventable and 13.6% had resulted in death - that's 150 patients who went into the system hoping - maybe believing - for the best, not knowing that they would become victims of errors.  

Here's another one:  In the UK a study published in 2001 estimated that 1 in 10 people suffered harm in hospitals from a variety of mistakes.  And it goes on.... and on...

I'm persuaded, having been the victim of an abusive nurse after 9.5 hours of surgery.  Anything is possible.

One of the answers, says Woodward, is to take a look at how other high-risk industries handle human factors, scheduling, drug procedures, and communications.  In fact, one of the key parallel industries is aviation safety, an activity that spans global languages, cultures, IT systems, as well as customer demands.  In addition to formulating agreement on the top seven essential safety priorities, as well as shifting from a "one size fits all" to an "intelligent approach to risk"  the author examines what makes implementation of safety across specific areas so very challenging.

Loaded with pointed examples, Rethinking Patient Safety not only gives one pause for thought, it offers alternative approaches and a more patient-focused methodology.  Chapter 8, "The Impact on Front-line Workers,"  gets very specific with its look at Bob's Story, Kimberley's Story, Richie's Story, along with suggested reading.  This book is a departure from formulaic lean healthcare pieces tossed from manufacturing into healthcare organizations.  

"For further reading" list includes texts, studies, and TED talks - very approachable.