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Emslie S, Knox K, Pickstone M, eds. London: ECRI and Department of Health, 2002. £35.00. 104 pp. ISBN 094141775 1
What happened when a medical devices officer decided to explore the cupboards at his hospital is one of the most attention grabbing parts of this book. Chris Quinn, from Newcastle upon Tyne Hospitals NHS Trust in the UK, found more than 40 kinds of infusion pumps, 25 of which were obsolete, and discovered that no nurse had received competency based training in their use. An increase in infusion incidents between 1993 and 1996 has now been reversed at the Trust thanks to a training programme and the growth of what Mr Quinn describes as “a culture of safety”.
The theme of a safety culture runs through the book, which takes the form of abridged transcripts of speakers' presentations at a conference to introduce the UK's National Patient Safety Agency (NPSA) in 2001. It is edited by the speakers and is therefore an accurate account of the day's events. It contains some good material.
Since the publication of An Organisation with a Memory in 2000 there has been an increasing emphasis on patient safety in the UK's NHS, and the first few presentations in the book are therefore concerned with initial steps in this direction and with the launch of the NPSA. For example, the then head of controls assurance at the Department of Health, Stuart Emslie, outlines the new national system for learning from adverse incidents in the context of the governance and controls assurance agenda. He adds that one could argue that underinvestment in health service management is a significant factor in the high incidence of preventable harm to patients. As the previous speaker, health minister Lord Hunt, points out, this costs the taxpayer money: prolonged hospital stays due to adverse events cost the NHS at least £2bn a year.
Presentations from America, Australia and New Zealand add an international dimension to the book. Dr Paul Barach from the University of Chicago's Center for Patient Safety talks of improving patient safety by “replacing the fragmented approach by teamwork, and inviting the patient into the system”, while director of the Veterans' Health Administration's National Center for Patient Safety, Dr James Bagian, warns of the potentially dire consequences of failing to protect the confidentiality of those making reports. He says that the civil aviation authorities in New Zealand once revealed the name of a captain who made a report: as a result their system lost the trust of the aviation community and was disbanded.
The book carries case studies and examples from a variety of health systems, and these will perhaps be of most interest to readers trying to improve patient safety day-to-day. Professor Bill Runciman, President of the Australian Patient Safety Foundation, discusses improvements in prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) and the use of pulse oximeters, while examples from the UK such as Professor Nick Barber's work on medication errors and the work of Chris Quinn are particularly likely to resonate with the home audience.
All in all, the book adds to the background knowledge about patient safety and is particularly strong when it talks about solutions to patient safety problems. Some parts are starting to look dated—for example, where the work of the NPSA is concerned—as there have been many developments since October 2001, but overall it is a valuable read for those thinking about and implementing patient safety measures.
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