Download - What’s so tough about patient safety?
![Page 1: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/1.jpg)
Mary Dixon-Woods
Professor of Medical Sociology and
Wellcome Trust Investigator
University of Leicester
@MaryDixonWoods
What’s so tough about patient safety?
![Page 2: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/2.jpg)
• It’s hard to know whether care is safe
• Fugitive knowledge and structural secrecy
• Ironies of measurement
• Magical thinking in safety improvement
• Getting the technical stuff and the implementation right
• The problem of many hands
![Page 3: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/3.jpg)
It’s hard to know whether care is safe
![Page 4: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/4.jpg)
No single measure
![Page 5: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/5.jpg)
![Page 6: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/6.jpg)
Measuring rates of harm
• Very easy to underestimate the technical difficulties of measurement
• Instrumentation is poor and difficult to use
![Page 7: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/7.jpg)
"Kielbasa7" by Mariuszjbie - Own work. Licensed under CC BY 3.0 via Wikimedia Commons -
http://commons.wikimedia.org/wiki/File:Kielbasa7.jpg#/media/File:Kielbasa7.jpg
![Page 8: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/8.jpg)
Measurement
8
![Page 9: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/9.jpg)
Measuring harms
• Challenges in establishing data collection systems are formidable
• Issues of comparability poorly understood
![Page 10: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/10.jpg)
Past harm
• Important but imperfect good guide to current safety
![Page 11: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/11.jpg)
Incubation period
• Latent errors and events accumulate
• Failures of intelligence
• Drifts in what is considered acceptable or unacceptable
• Discounting of warning signs
![Page 12: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/12.jpg)
William Petty
![Page 13: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/13.jpg)
" https://commons.wikimedia.org/wiki/File:Collapsing_bridge_on_the_C_5_incline_-_geograph.org.uk_-_286439.jpg?uselang=en-gb
![Page 14: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/14.jpg)
![Page 15: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/15.jpg)
http://www.health.org.uk/
![Page 16: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/16.jpg)
![Page 17: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/17.jpg)
![Page 18: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/18.jpg)
Healthcare systems
• Piecemeal systems – nobody has ever designed them
• How they function in practice is often poorly understood
• Ad hoc improvisations and adaptations are the norm
• Limited understanding of what it takes to achieve peak performance
• The blunt end often has very poor grasp of the operational detail at the sharp end
![Page 19: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/19.jpg)
![Page 20: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/20.jpg)
Fugitive knowledge and structural secrecy
![Page 21: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/21.jpg)
Fugitive knowledge
• Evades capture
• May be forbidden
• Uncertain evidence
![Page 22: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/22.jpg)
Silencing and secrecy
“the way that patterns of information, organizational structure, processes, and transactions, and the structure of regulatory relations systematically undermines the attempt to know” (Vaughan: The
Challenger Launch Decision)
![Page 23: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/23.jpg)
Normalization of deviance
• Poorly designed systems
• Workarounds and short-cuts
• No harm, no foul mentality makes it hard to challenge
http://30yearoldninja.com/10-absurd-cartoons-inspire-disturb/
![Page 24: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/24.jpg)
http://qualitysafety.bmj.com/content/early/2013/08/28/bmjqs-2013-001947.full
![Page 25: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/25.jpg)
Intelligence
• Problem-sensing versus comfort-seeking behaviours
![Page 26: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/26.jpg)
Peter M Dunn Arch Dis Child Fetal Neonatal Ed
1998;78:F232-F233
Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.
1795, Aberdeen
![Page 27: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/27.jpg)
1843, Boston
![Page 28: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/28.jpg)
“Doctors are gentlemen, and a gentleman’s hands are clean.”
(Charles Meigs)
![Page 29: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/29.jpg)
1861, Vienna
![Page 30: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/30.jpg)
Entitlement to speak
• Job status or experience
• Evidentiary support
• Ability to use personal social capital and tolerate threats to it
https://www.flickr.com/photos/medilldc/5815309247
![Page 31: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/31.jpg)
Avoiding conflict is often a priority
![Page 32: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/32.jpg)
Listening is not a simple function of hearing
![Page 33: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/33.jpg)
The problem of many voices
![Page 34: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/34.jpg)
January 2005, Texas
![Page 35: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/35.jpg)
March 2005, Texas
• Hydrocarbon vapour cloud explosion kills 15, injures 170 more
![Page 36: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/36.jpg)
April 20 2010, Gulf of Mexico
• Senior officials visited the rig to celebrate zero personal injuries for 7 years
![Page 37: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/37.jpg)
The oil rig
• Senior officials visited the rig to celebrate zero personal injuries for 7 years
• Later that day, the rig caught fire
![Page 38: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/38.jpg)
The oil rig
• Senior officials visited the rig to celebrate zero personal injuries for 7 years
• Later that day, the rig caught fire
• Two days later, it sank
![Page 39: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/39.jpg)
The oil rig
• Senior officials visited the rig to celebrate zero personal injuries for 7 years
• Later that day, the rig caught fire
• Two days later, it sank
• The oil spill caused the worst environmental disaster in US history
![Page 40: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/40.jpg)
March 2010, Gulf of Mexico
![Page 41: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/41.jpg)
Ironies of measurement
![Page 42: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/42.jpg)
Policy space
• Multiple bodies can exercise control functions in a healthcare system
• Even when they are not explicitly defined as regulators
https://www.flickr.com/photos/lens_envy/
![Page 43: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/43.jpg)
Policy incentives
• Too often the incentives conflict, compete, or fail to cohere
• Unintended or unwanted consequences
""Problems, problems..." (70-ies). (6548084971)" by Ion Chibzii from Chisinau. , Moldova. - "Problems, problems..." (70-ies).. Licensed under CC BY-SA 2.0 via Wikimedia Commons -https://commons.wikimedia.org/wiki/File:%22Problems,_problems...%22_(70-ies)._(6548084971).jpg#/media/File:%22Problems,_problems...%22_(70-ies)._(6548084971).jpg
![Page 44: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/44.jpg)
![Page 45: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/45.jpg)
Measuring too much
• In the US, National Quality Forum measures went from 200 in 2005 to over 700 in 2011
• US CMS introduced 65 new measures in 2011 alone• At MGH, measuring consumes 1% of net patient
service revenue
![Page 46: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/46.jpg)
Priority thickets
• Too many externally imposed priorities
• Distraction, frustration, loss of focus and energy
46
![Page 47: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/47.jpg)
Left unmeasured
![Page 48: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/48.jpg)
• Clarity of goals
• Importance of warm, supportive human resources management
• Well-functioning teams
48BMJ Quality and Safety, Sept 2013 [online early]
![Page 49: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/49.jpg)
![Page 50: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/50.jpg)
Measurement done badly
• Illusion of control
• Blindsight
![Page 51: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/51.jpg)
Performativity of measurement
![Page 52: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/52.jpg)
The reactivity of measurement
• Measurement acts on what it measures
![Page 53: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/53.jpg)
Two known reactive effects
• Gaming and effort substitution
![Page 54: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/54.jpg)
Targets and terror
• People become adept at working out what they need to do to survive performance management
![Page 55: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/55.jpg)
![Page 56: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/56.jpg)
Effort substitution
• Focusing effort on the thing being measured
• Taking your eye off other balls
![Page 57: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/57.jpg)
Outbreaks of unmonitored infections
• May occur when some infections are monitored but others are not
• Other managerial imperatives were given greater priority than the control of infection. At the most senior level of management, there was a lack of effective leadership, accountability and support for the control of infection. The director of infection prevention and control had not persuaded the board to give sufficient priority to the control of infection in general and to the control of C. Difficile in particular. The achievement of the Government's targets was seen as more important than the management of the clinical risk inherent in the outbreaks of C. Difficile
Healthcare Commission. Investigation into outbreaks of Clostridium difficile at Stoke Mandeville hospital, Buckinghamshire hospitals NHS trust. United Kingdom: Healthcare Commission 2006;.
![Page 58: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/58.jpg)
![Page 59: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/59.jpg)
Bureaucratised, defensive management
• Reactive
• Focused on auditable moments and visible traces of compliance
• Proliferation of forms, procedures and rules
59
![Page 60: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/60.jpg)
Magical thinking in safety improvement
![Page 61: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/61.jpg)
Conspiracy of enthusiasm
• Specific reforms are advocated as though they were certain to be successful…We must be able to advocate without that excess of commitment that blinds us to reality testing” (Donald Campbell, 1969: 72)
![Page 62: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/62.jpg)
Magical thinking in improvement programs
![Page 63: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/63.jpg)
"Steam Train at Amersham Station - geograph.org.uk - 56745" by Christine Matthews. Licensed under CC BY-SA 2.0 via Wikimedia Commons -http://commons.wikimedia.org/wiki/File:Steam_Train_at_Amersham_Station_-_geograph.org.uk_-_56745.jpg#/media/File:Steam_Train_at_Amersham_Station_-_geograph.org.uk_-_56745.jpg
![Page 64: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/64.jpg)
![Page 65: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/65.jpg)
Introduce
an
incident
reporting
system
Errors go
down
![Page 66: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/66.jpg)
•Then a miracle occursccursIntroduce
an
incident
reporting
system
Errors go
down
![Page 67: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/67.jpg)
Not optimising design of interventions
![Page 68: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/68.jpg)
![Page 69: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/69.jpg)
Failure to be aware of unintended consequences
• Ironies of automation
![Page 70: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/70.jpg)
In safety improvement work….
• Limited understanding of the mechanisms
• Poor descriptions of intervention, implementation and context
• Discounting of the organisational, social and emotional work
![Page 71: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/71.jpg)
![Page 72: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/72.jpg)
![Page 73: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/73.jpg)
![Page 74: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/74.jpg)
• In hospital 1, the checklist associated with improved outcomes but not improved compliance
• In hospital 2, improved compliance but not improved outcomes
![Page 75: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/75.jpg)
![Page 76: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/76.jpg)
![Page 77: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/77.jpg)
![Page 78: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/78.jpg)
• No doubt the principles behind the checklist are good ones
• But the mechanisms through which it works (technical, implementation, context) need to be clearer
• It’s not as simple as saying “here it is, off you go”
![Page 79: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/79.jpg)
Getting the technical stuff and the implementation right
![Page 80: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/80.jpg)
Some simple but often neglected questions
• Does the technical intervention work?
• Does the implementation strategy work?
• Were there features of context that intervened?
![Page 81: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/81.jpg)
![Page 82: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/82.jpg)
"Harry Potter and the Goblet of Fire Poster" by Source. Licensed under Fair use via Wikipedia -
http://en.wikipedia.org/wiki/File:Harry_Potter_and_the_Goblet_of_Fire_Poster.jpg#/media/File:Harry_Potter_and_the_Goblet_of_F ire_Poster.jpg
![Page 83: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/83.jpg)
![Page 84: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/84.jpg)
1685
![Page 85: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/85.jpg)
Technical intervention wrong
![Page 86: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/86.jpg)
Implementation thwarted
![Page 87: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/87.jpg)
![Page 88: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/88.jpg)
The problem of many hands
![Page 89: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/89.jpg)
QI is an essential capacity for healthcare organisations
![Page 90: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/90.jpg)
QI as the solution to patient safety?
"Xbar chart for a paired xbar and R chart" by DanielPenfield - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons -
http://commons.wikimedia.org/wiki/File:Xbar_chart_for_a_paired_xbar_and_R_chart.svg#/media/File:Xbar_chart_for_a_paired_xbar_and_R_chart.svg
![Page 91: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/91.jpg)
"Seat belt BX" by M.Minderhoud - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons -
http://commons.wikimedia.org/wiki/File:Seat_belt_BX.jpg#/media/File:Seat_belt_BX.jpg
![Page 92: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/92.jpg)
http://www.health.org.uk/
![Page 93: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/93.jpg)
The problem of ‘many hands’
“when many hands are involved… the profusion of agents obscures the location of agency” (Thompson, 2014)
![Page 94: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/94.jpg)
• Many of the issues underlying safety and quality are BIG and HAIRY
![Page 95: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/95.jpg)
Healthcare
• Consistently treats patient safety as an organizational problem
• Not an institutional or global one.
![Page 96: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/96.jpg)
Structural amnesia: 1986
![Page 97: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/97.jpg)
![Page 98: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/98.jpg)
1912
![Page 99: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/99.jpg)
![Page 100: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/100.jpg)
https://www.flickr.com/photos/crystalwriter/2327400376/
![Page 101: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/101.jpg)
Regional Tender Award for ID Bands
![Page 102: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/102.jpg)
Local, non-scaled solutions can be dangerous
![Page 103: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/103.jpg)
Conclusions
![Page 104: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/104.jpg)
Patient safety as a social problem
• Many bad outcomes are socially organized –in principle they can be anticipated, prevented or mitigated
• Organizational and institutional sclerosis obscures danger and frustrates rapid response
![Page 105: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/105.jpg)
Intelligence
• If you’re not measuring, you’re not managing
![Page 106: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/106.jpg)
Intelligence
• If you’re not measuring, you’re not managing
![Page 107: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/107.jpg)
Intelligence
• If you’re not measuring, you’re not managing
• If you’re measuring stupidly, you’re not managing
![Page 108: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/108.jpg)
Intelligence
• If you’re not measuring, you’re not managing
• If you’re measuring stupidly, you’re not managing
• If you’re only measuring, you’re not managing
![Page 109: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/109.jpg)
Coordinating action
• Sometimes elements of system need close alignment and integration, sometimes need to operate largely independently
• Need identified points of authority and arrangements for coordination, but also agility
https://www.flickr.com/photos/artotemsco/4761551981/
![Page 110: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/110.jpg)
Conclusions
• The science of patient safety needs to mature
• Better intelligence
• Better design of improvement efforts
• Better evaluation
• Better understanding of relationship between blunt end and sharp end of systems
![Page 111: What’s so tough about patient safety?](https://reader033.vdocument.in/reader033/viewer/2022051204/6277dc7b029d846af33679f5/html5/thumbnails/111.jpg)
Thanks
• Some research reported here was funded as an independent programme by the Policy Research Programme in the Department of Health. The views and opinions expressed in this report are those of the authors and do not necessarily reflect those of the Policy Research Programme, nor the Department of Health.
• Health Foundation
• Wellcome Trust
• Wellcome Trust Image Collection
111