30th Anniversary Invited Editorial reflecting on: Henry B. (2000) Quality of care, health system errors, and nurses. Journal of Advanced Nursing 32(4), 773–775
In the relatively short period since Beverly Henry's Editorial was published in JAN (Henry 2000), safety has become a topic that is now constantly in the spotlight. It is no longer just the concern of healthcare planners, providers and purchasers, but also of open concern among health service users, the public at large and, therefore, the media as well. Safety is, without doubt, an important topic for continuous discussion since the consequences of unsafe care and errors can be severe in healthcare organizations. Unsafe care can result in human suffering, additional financial expenditure, and even the loss of life. For example, studies in the United States of America (USA) have estimated that medical errors in the healthcare sector cost $37·6 billion each year and approximately $17 billion of these costs are related to preventable errors. About half of the expenditures for preventable medical errors are for direct healthcare costs [Agency for Healthcare Research and Quality (AHRQ) 2000]. Similar kinds of statistics are available in many other countries all over the world.
In her 2000 JAN Editorial, Henry was writing about safety mainly in terms of the culture of blaming, and the negative effects of this approach on attempts to improve standards of safety. It may be true, as Henry argued, that a reason for errors lies in problems of system design. ‘Think systems!’, she advocated. However, it is also possible to argue that, in complex and modern healthcare organizations, errors, unsafe acts and accidents are not necessarily always initiated by system design defects. Continuous changes and new, unanticipated situations are creating safety risks that are not incorporated in system design. Changes and emerging safety risks may first be noticed by the staff ‘on the ground’, not necessarily by nursing (and other) managers: therefore, safety issues and how they are reflected in standards, procedures, rules and protocols present a challenge to nurses at first hand. As Auffrey (2005) pointed out in a more recent JAN Editorial also on the topic of safety, nurses are in an optimal position to strengthen the patient safety net and increase safety in healthcare organizations.
Auffrey's (2005) Editorial was prompted by the Canadian Adverse Events Study in which the adverse events incidence rate in Canadian hospitals was found to be 7·5%, this echoing findings from similar studies in the USA, United Kingdom (UK) and Australia. In other words, studies in different countries and different types of healthcare systems have shown that even in the best healthcare systems, or regardless of the system, safety risks are always present in health care. These risks do not only affect patients: staff safety as well may be compromised. The reasons are complex, including system failures.
After reflecting on the earlier Editorials published in JAN (Henry 2000, Auffrey 2005), we were left pondering the question: Is it really possible that healthcare organizations throughout the world are still lacking the mechanisms and coordination to ensure the basic right of safety to patients and staff? Despite all the evidence available today, why do the systems still fail, and why is research not providing definitive answers to safety risks and related problems?
When considering the available literature, including recent publications, it is clear that safety is a multi-faceted issue. The complex and multi-faceted nature of ‘safety’ is demonstrated by the wide range of topics and the various approaches to risk management that authors and researchers have addressed. Environment, patient, employee, and equipment safety are just a few examples of the perspectives examined in healthcare organizations. However, the complexity of ‘safety’ does not seem to translate into the commonly used definitions: for example, in defining ‘safety’ as ‘freedom from accidental injury’, or defining ‘error’ as ‘the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim’ (Institute of Medicine 2000). So the question arises: how should we define ‘safety’ today for clinical and research purposes so that we can build a ‘safety-net’ in healthcare organizations that can adapt to continuous change but, at the same time, also increases safety to its maximum level?
In a recent study, Hansen et al. (2003) used a focus group technique to study and define patient safety in a multi-professional group. The findings of the study were interesting, but not surprising. ‘Patient safety’ was found difficult to define because of its evolving nature and the public's changing perceptions of its meaning. The consensus definition that emerged in Hansen et al.’s study was in terms of ‘do no harm’. The findings of their study demonstrated that the major barriers to patient safety were related mainly to environmental and financial issues: (1) ‘production pressure’ resulting in a lack of time; (2) communication barriers; and (3) regulatory/ legal barriers, such as too many regulations, administrative burden, and tortuous legal risks. Hansen et al.’s paper suggested that there is a need for a paradigm shift in terms of how we approach safety issues.
Cooper et al. (2000) point in their article to the need for a wider and more comprehensive perspective as well, since simple failures or mistakes of healthcare professionals are rarely the cause of patient injury. More often, injuries or accidents are the result of flaws in complex interactions among several individuals, the technologies they use and the organizations in which they work. In other words, every activity in a heathcare setting has a potential for weakness that may compromise patient and/or staff safety. Unfortunately, these weaknesses are often hidden until a unique combination of circumstances result in a near-miss or an actual injury. Efforts to improve safety in health care are hampered by the lack of robust evidence which, in turn, is due, at least in part, to the methodological difficulties attached to research in this area.
The theoretical and methodological challenges inherent in investigating safety are an interesting and timely topic for healthcare professionals to consider. Thomas and Houston (2005) recently published a paper exploring and discussing different theoretical approaches for patient safety studies. The authors introduced three theoretical models that they believe can provide helpful frameworks for exploring the phenomenon of safety: Complexity Sciences, Human Error Model, and Threat and Error Management Model. In brief, Complexity Sciences explores social order and leads to re-examination of organizational and individual relationships. The assumption is that these theories are suitable for examining safety because errors often occur in the kind of chaos and complexity that characterizes modern healthcare environments. The Human Error Model and the Threat and Error Management Model provide frameworks for examining error occurrence as well. Both of these models evolve from the human factor sciences and promote an examination of human and systems components that may lead to error.
We found the theoretical approaches presented in Thomas and Houston's (2005) paper very interesting and, inspired by their suggestions, we decided to re-visit the safety culture in our own organization (Maine Medical Centre). Our observations and insights were astonishing: the approaches suggested by Thomas and Houston (2005) seemed suitable for describing, studying and maybe developing further at least 10 safety actions in current practice: for example, our Rapid Response Team (RRT). The RRT is composed of a critical care nurse and respiratory therapist who respond to nurses working on medical and surgical units when they request a consultation on the status of a patient. The RRT's work is based on two principles: firstly, it is not a resuscitation team and, secondly, it is consulted when ‘something is not right with a patient’. The innovation of this preventive safety action and support for nurses already has resulted in a 34% reduction in the number of patients returning from wards to the ICU, and a 40% reduction in resuscitation on the medical and surgical units. The RRT's successful work probably could be further enhanced by applying a theoretical framework to promote understanding of its workings and guide its development and evaluation.
There is, we believe, an opportunity to further the quest for patient quality and safety through research and development that applies the theoretical concepts of complexity sciences and human error models. We encourage you to consider this and, in general, we encourage you to take yet another look at the safety culture that is present in your organization. That is what we did as a direct result of being asked to reflect on Henry's (2000)JAN Editorial. It remains the case, as she said then, that ‘we are doing better…but we have a long way to go!’