Preamble
The progress in science and technology, combined with advanced specialisation in health care are leading to increasingly complex care situations for increasingly frail patients. We should realise that health care is becoming less safe, partly because of this enormous progress in hospital care. Making errors is a normal, but with regard to outcome often undesired, deviation in human behaviour. The risk of errors increases in complex situations with hierarchical relationships. To be able to reduce the risk of errors and incidents in hospitals, many different actions could be undertaken. These will be discussed further.
Increasing attention to and action on safety problems is urgently needed. Unfortunately, up to now there is limited scientific evidence on the effectiveness of specific interventions. We are forced to use whatever evidence or expe-
rience is available, combined with the analysis and understanding of the problem and the local situation, when selecting actions that should be undertaken in a given organization. The project has developed an overview of these actions / instruments, that is being presented for discussion. However, even as we are discussing them new knowledge is being generated about the ones listed here and new innovative approaches are being initiated.
Therefore the key issue being presented here for discussion is:
What would be the ways and means of further cooperation in Europe in order to increase learning, knowledge and exchange related to different approaches to improve patient safety and facilitate their implementation in health care organizations?
Introduction
“Primum non nocere”
Patient safety: the hidden problem in our health care system. Health care has as its mission to cure and to relief suffering the best we can according to the “state of the art“-scientific knowledge, realizing that our “object of care” is a fellow human being. All professionals and managers agree to this mission with their whole heart. But, at the same time we harm patients unintentionally by the way we organize and deliver care: professional by over- and underuse (and sometimes misuse) of effective care, organisational by making healthcare too complicated and fragmented and relational by forgetting that our patient is a human being with insecurities, feelings and specific needs.
The IOM-report “To err is human” (USA, 1999) (1) did highlight this “hidden” problem in a comprehensive, not blaming way with the intention to create a culture of learning and improvement in stead of the usual “naming, blaming and shaming”. This report has effected a big impact in many countries. The confronting facts about the lack of patient safety in our healthcare system have been confirmed in many countrywide research projects since. What we still consider acceptable in our healthcare system would be totally unacceptable in other industries. That’s one of the reasons we can learn a lot from the approach and results to assure safety in airline industries, oil companies, nuclear power plants, etc.
In many countries numerous initiatives have been taken – both national and within healthcare institutions – to promote patient safety. The results are inspiring to continue on this road. Patient safety management is a clear distinguishable, but inseparable part of our quality management system, that should be part of our normal management and leadership systems, both professional and managerial.
This book is written for professional and managerial leaders on all levels and for everyone who is really motivated to make healthcare a safe place for patients.
The book's emphasis is on learning and improvement, seeing the real facts, but at the same time asking the basic questions of “five times why” to discover the root causes of unsafety, that harm patients and to offer solutions that have been proven successful. It helps professional and managerial leaders to build a strategy for improving safety: a patient safety management system. It offers tools and instruments both to pro-active improve patient safety, and to reactive learn from what has gone (almost) wrong. It also address the way leaders need to take initiatieve to change the culture of the organisation into a learning, blame free environment: especially by their own personal example in the way they manage.
In this effort professionals, managers, leaders on all levels have to collaborate to get breakthrough results.
The challenge after reading this book is on doing: applying what has proven to be successful.
Our mission is to cure and relief suffering not to (unintentionally) harm patients:
“Primum non nocere”
