International Journal of Health Policy and Management

International Journal of Health Policy and Management

False Dawns and New Horizons in Patient Safety Research and Practice

Document Type : Editorial

Authors
Russell Mannion 1
Jeffrey Braithwaite 2
1 Health Services Management Centre, University of Birmingham, Birmingham, UK
2 Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
10.15171/ijhpm.2017.115
Abstract
In response to a weight of evidence that patients are frequently harmed as a result of their care, there have been concerted efforts to make healthcare safer, with health systems across the globe investing significant resources in policies and programmes designed to reduce adverse events. Yet, despite extensive efforts, improvements in safety have proved difficult to sustain and spread, with studies confirming there has been no measurable, systemslevel improvement in the overall rates of preventable harm. Here, we highlight the limitations of the thinking which underpins current efforts to make healthcare systems safer and point to new and emerging approaches to understanding and addressing patient safety in complex, dynamic health systems.

Highlights

Commentaries Published on this Paper

  • It Ain’t What You Do (But the Way That You Do It): Will Safety II Transform the Way We Do Patient Safety; Comment on “False Dawns and New Horizons in Patient Safety Research and Practice”

          Abstract | PDF

  • A Safety-II Perspective on Organisational Learning in Healthcare Organisations; Comment on “False Dawns and New Horizons in Patient Safety Research and Practice”

          Abstract | PDF

  • The Rise of Patient Safety-II: Should We Give Up Hope on Safety-I and Extracting Value From Patient Safety Incidents?; Comment on “False Dawns and New Horizons in Patient Safety Research and Practice”

          Abstract | PDF

  • Safety I to Safety II: A Paradigm Shift or More Work as Imagined?; Comment on “False Dawns and New Horizons in Patient Safety Research and Practice”

          Abstract | PDF

  • Disturbing the Doxa of Patient Safety; Comment on “False Dawns and New Horizons in Patient Safety Research and Practice”

          Abstract | PDF

 

Authors' Response to the Commentaries

  • Where is Patient Safety Research and Practice Heading? A Response to Recent Commentaries

          Abstract | PDF

Keywords
Health System
Patient Safety
Adverse Events
Preventable Harm
System Thinking
Subjects
  1. Porter R. The Greatest Benefit to Mankind: A Medical History of Humanity From Antiquity to the Present. London, UK: Harper Collins; 1999.
  2. Braithwaite J, Donaldson L. Patient safety and quality. In: Ferlie E, Montgomery K, Pederson AR, eds. The Oxford Handbook of Health Care Management. Oxford, UK: Oxford University Press; 2016:325-351.
  3. World Health Organization. Patient safety: making health care safer. Geneva, Switzerland: World Health Organization; 2017.
  4. Braithwaite J, Wears RL, Hollnagel E, eds. Resilient Health Care Volume 3: Reconciling Work-as-Imagined and Work-as-Done. Abingdon, UK: Taylor & Francis; 2016.
  5. McGlynn  EA, Asch  SM, Adams  J, et al. The Quality of Health Care Delivered to Adults in the United States. N Engl J Med. 2003;348(26):2635-2645. doi:10.1056/NEJMsa022615
  6. Runciman WB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012;197(2):100-105.
  7. Hooper TD, Hibbert PD, Mealing N, et al. CareTrack Kids—part 2. Assessing the appropriateness of the healthcare delivered to Australian children: study protocol for a retrospective medical record review. BMJ Open. 2015;5(4):e007749. doi:10.1136/bmjopen-2015-007749
  8. Slawomirski L, Auraaen A, Klazinga N. The Economics of Patient Safety: Strengthening a Value-Based Approach to Reducing Patient Harm at National Level. https://www.oecd.org/els/health-systems/The-economics-of-patient-safety-March-2017.pdf. Published 2017.
  9. DeVita MA, Hillman K, Bellomo R, et al, eds. Textbook of Rapid Response Systems: Concept and Implementation. New York, NY: Springer; 2017.
  10. Allen D, Braithwaite J, Sandall J, Waring J, eds. The Sociology of Healthcare Safety and Quality. West Sussex, UK: Wiley-Blackwell; 2016.
  11. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732. doi:10.1056/NEJMoa061115
  12. Haynes  AB, Weiser  TG, Berry  WR, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med. 2009;360(5):491-499. doi:10.1056/NEJMsa0810119
  13. Hillman K, Nosrati H, Braithwaite J. RRS and the Culture of Safety. In: DeVita MA, Hillman K, Bellomo R, eds. Textbook of Rapid Response Systems. Cham, Switzerland: Springer International Publishing; 2017:53-57.
  14. Braithwaite J, Wears RL, Hollnagel E. Resilient health care: turning patient safety on its head. Int J Qual Health Care. 2015;27(5):418-420. doi:10.1093/intqhc/mzv063
  15. Rittel HWJ, Webber MM. Dilemmas in a general theory of planning. Policy Sci. 1973;4(2):155-169. doi:10.1007/bf01405730
  16. Braithwaite J, Runciman WB, Merry AF. Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Qual Saf Health Care. 2009;18(1):37.
  17. Baker R, Hurwitz B. Intentionally harmful violations and patient safety: the example of Harold Shipman. J R Soc Med. 2009;102(6):223-227. doi:10.1258/jrsm.2009.09k028
  18. Hindle D, Braithwaite J, Iedema R. Patient safety Research: a Review of the Technical Literature. Sydney, Australia: University of New South Wales; 2006.
  19. Reason J. Human Error. Cambridge, UK: Cambridge University Press; 1990.
  20. Mannion R, Davies H, Marshall MN. Cultures for Performance in Health Care. Milton Keynes, UK: Open University Press; 2005.
  21. Heinrich HW. Industrial Accident Prevention: A Scientific Approach. New York, NY: McGraw-Hill; 1931.
  22. Parker D, Wensing M, Esmail A, Valderas JM. Measurement tools and process indicators of patient safety culture in primary care. A mixed methods study by the LINNEAUS collaboration on patient safety in primary care. Eur J Gen Pract. 2015;21(suppl 1):26-30. doi:10.3109/13814788.2015.1043732
  23. Braithwaite J, Churruca K, Ellis LA. Can we fix the uber-complexities of healthcare? J R Soc Med. 2017; forthcoming.
  24. Sweeney KG, Mannion R. Complexity and clinical governance: using the insights to develop the strategy. Br J Gen Pract. 2002;52(Suppl):S4-S9.
  25. Mannion R, Exworthy M. (Re) Making the procrustean bed? Standardization and customization as competing logics in healthcare. Int J Health Policy Manag. 2017;6(6):301-304. doi:10.15171/ijhpm.2017.35
  26. Mannion R, Braithwaite J. Unintended consequences of performance measurement in healthcare: 20 salutary lessons from the English National Health Service. Internal Medicine Journal. 2012;42(5):569-574. doi:10.1111/j.1445-5994.2012.02766.x
  27. Braithwaite J, Hyde P, Pope C, eds. Culture and Climate in Health Care Organizations. New York, NY: Palgrave Macmillan; 2010.
  28. Hollnagel E, Braithwaite J, Wears RL, eds. Resilient Health Care. Farnham, Surrey: Ashgate Publishing Ltd; 2013.
  29. Debono D, Clay-Williams R, Taylor N, Greenfield D, Black D, Braithwaite J. Using workarounds to examine characteristics of resilience in action. In: Hollnagel E, Braithwaite J, Wears RL, eds. The Field Guide to Resilient Health Care. Farnham, Surrey: Ashgate Publishing Ltd; In Press.
  30. Debono DS, Greenfield D, Travaglia JF, et al. Nurses' workarounds in acute healthcare settings: a scoping review. BMC Health Serv Res. 2013;13:175. doi:10.1186/1472-6963-13-175
  31. Wears RL, Hollnagel E, Braithwaite J, eds. Resilient Health Care Volume. 2: The Resilience of Everyday Clinical Work. Farnham, Surrey: Ashgate Publishing Ltd; 2015.
  32. Braithwaite J, Churruca K, Ellis LA, et al. Complexity Science in Healthcare – Aspirations, Approaches, Applications and Accomplishments: A White Paper. 2017.
  33. Wears RL, Hunte G. Resilient procedures: oxymoron or innovation? In: Braithwaite J, Wears RL, Hollnagel E, eds. Resilient Health Care Volume 3: Reconciling Work-as-Imagined and Work-as-Done. Abingdon, UK: Taylor & Francis; 2016:163-170.
  34. Davies HTO, Mannion R. Will prescriptions for cultural change improve the NHS? BMJ. 2013;346:f1305. doi:10.1136/bmj.f1305
  35. Mannion R, Davies H. Cultures in Healthcare. In: Ferlie E, Montgomery K, Pedersen AR, eds. The Oxford Handbook of Health Care Management. Oxford, UK: Oxford University Press; 2016.
  36. Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Reality check for checklists. Lancet. 2009;374(9688):444-445. doi:10.1016/S0140-6736(09)61440-9
  37. Greenhalgh T, Plsek P, Wilson T, Fraser S, Holt T. Response to 'The appropriation of complexity theory in health care'. J Health Serv Res Policy. 2010;15(2):115-117. doi:10.1258/jhsrp.2010.009158
  38. Hawe P. Lessons from complex interventions to improve health. Annu Rev Public Health. 2015;36:307-323. doi:10.1146/annurev-publhealth-031912-114421
  39. Hawe P, Bond L, Butler H. Knowledge theories can inform evaluation practice: What can a complexity lens add? New Directions for Evaluation. 2009;2009(124):89-100. doi:10.1002/ev.316
  40. Plsek PE, Greenhalgh T. The challenge of complexity in health care. BMJ. 2001;323(7313):625.
  41. Leykum LK, Lanham HJ, Pugh JA, et al. Manifestations and implications of uncertainty for improving healthcare systems: an analysis of observational and interventional studies grounded in complexity science. Implement Sci. 2014;9:165. doi:10.1186/s13012-014-0165-1
  42. Freeman T, Millar R, Mannion R, Davies H. Enacting corporate governance of healthcare safety and quality: a dramaturgy of hospital boards in England. Sociol Health Illn. 2016;38(2):233-251. doi:10.1111/1467-9566.12309
  43. Rhodes P, Campbell S, Sanders C. Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study. Health Expect. 2016;19(2):253-263. doi:10.1111/hex.12342
International Journal of Health Policy and Management
Volume 6, Issue 12
2017
Pages 685-689

  • Received Date 11 September 2017
  • Revised Date 19 September 2017
  • Accepted Date 16 September 2017
  • First Published Date 01 December 2017
  • Published Date 01 December 2017