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Managing risk in hazardous conditions: improvisation is not enough
  1. Rene Amalberti1,
  2. Charles Vincent2
  1. 1 FONCSI, Toulouse, France
  2. 2 Experimental Psychology, University of Oxford, London, UK
  1. Correspondence to Professor Rene Amalberti, FONCSI, Toulouse 31029, France; rene.amalberti{at}

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Healthcare systems are under stress as never before. An ageing population, increasing complexity and comorbidities, continual innovation, the ambition to allow unfettered access to care and the demands on professionals contrast sharply with the limited capacity of healthcare systems and the realities of financial austerity. This tension inevitably brings new and potentially serious hazards for patients and means that the overall quality of care frequently falls short of the standard expected by both patients and professionals. The early ambition of achieving consistently safe and high-quality care for all1 has not been realised and patients continue to be placed at risk. In this paper, we ask what strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to.

The evolution of poor performance

Teams and organisations constantly have to adapt to times of increased demand. Emergency departments, for instance, become adept at managing times of heightened activity and very sick patients. However, the adaptations are usually improvised and vary widely depending on who is in charge at the time. In contrast, for clinical emergencies such as failed intubation or cardiac arrest, clinicians have many well-rehearsed and adaptable routines.

In the short term, staff adapt and cope with the problems for a few hours or a few days until conditions are easier. However, if pressures continue, poor working conditions and deviations from best practice become increasingly common. For instance, the English Care Quality Commission reported that hospital bed occupancy rates are more or less permanently above the recommended maximum of 85% for acute hospitals. In these circumstances, staff are overburdened to the point that they cannot possible achieve expected standards. These pressures are exacerbated by patients with increasingly complex conditions, inadequate staffing, missing equipment and other constraints. Staff increasingly rely on …

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