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Reducing harm in hospital care using Human Factors and Quality Improvement approaches has proved harder than expected: better evaluation of our efforts, a more realistic understanding of the challenges we face and an intense focus on engaging staff are the key elements needed for progress.
Patient safety was not a recognised term in medical research parlance until the 1990s. Prior to this, avoidable harm from treatment was assumed to be rare, and failure was commonly attributed to the incompetence or lack of diligence of individuals. The emergence of convincing evidence that around 10% of hospital inpatients suffered serious harm from their treatment stimulated alarm, and a search for a rapid solution to this huge, previously unnoticed problem.1 Analyses of adverse events showed that their causes were usually complex, system-based and to some extent stochastic, echoing the typical findings of professional accident investigations in the transport and energy sectors. It seemed likely that systematic analysis of the underlying problems would result in effective solutions which could drastically reduce harm from treatment, and the concept of the high reliability organisation became hugely popular.2 Following the lead of civil aviation, healthcare professionals became enthusiastic about using ergonomics (Human Factors science) to solve the safety problem. Decades on, progress has been incremental, and studies of harm show results not dissimilar to those from the 1990s.3 4
So why are we not there yet?
There are several answers to this question. I focus here on the ones I think are most important, respectfully recognising the subjectivity in my position. First, there is a difference in the commitment of management and policymakers at the most senior level in healthcare when compared with leaders in airline companies and fossil fuel producers, for whom the massive financial consequences of a major accident were ever-present in safety decision-making. Second, the Human Factors approaches …
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Contributors This article draws on experience of the challenges of implementing quality and safety changes in healthcare organisations in England and the US. Professor PM is a surgeon by background and has led multiple research groups focused on improving the safety of surgical care and quality of surgical research. He would like to acknowledge the assistance of Ms Olivia Lounsbury, a US quality and safety practitioner and researcher focused on removing barriers to implementation of safety changes in healthcare organisations. The piece was first conceptualised from discussions between PM and Ms Lounsbury, and both consulted a variety of international healthcare journals for evidence on the topic. Ms Lounsbury commented on and edited drafts, but declined to be an author. Professor PM is the article’s guarantor, and declares that the opinions expressed in it are his alone.
Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.