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 Rethinking
Patient Safety
 Rethinking
Patient Safety

By Suzette Woodward
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2017 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-4987-7854-1 (Hardback)

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Library of Congress Cataloging‑ in‑ Publication Data

Names: Woodward, Suzette, author.

Title: Rethinking patient safety / Suzette Woodward.
Description: Boca Raton : Taylor & Francis, 2017. | Includes bibliographical
references.
Identifiers: LCCN 2016044132| ISBN 9781498778541 (hardback : alk. paper) |
ISBN 9781498778558 (ebook)
Subjects: LCSH: Medical errors--Prevention. | Medical care--Quality control.
| Patients--Safety measures.
Classification: LCC R729.8 .W66 2017 | DDC 610.28/9--dc23
LC record available at https://lccn.loc.gov/2016044132

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When you talk, you are only repeating what you already
know. But if you listen, you may learn something new.

Dalai Lama
Contents

Preface................................................................................... xi
Acknowledgements............................................................xiii
Introduction........................................................................ xv
Author................................................................................. xxi
1 Patient Safety............................................................1
What Is Patient Safety?......................................................... 1
Pioneers................................................................................ 3
Over One Hundred Years Later........................................... 7
Suggested Reading..............................................................10
2 The Scale of the Problem........................................11
Suggested Reading..............................................................19
3 A Culture of Learning.............................................21
Are We Learning from Harm? ............................................21
Learning the Johns Hopkins Way ......................................22
Impact on Patients and Their Families: Sam’ s Story .........25
Failing to Learn: My Own Story .........................................29
Suggested Reading ..............................................................33
4 Systems Approach to Safety...................................35
Understanding the Basics of a Safer System......................35
Learning from Other High-Risk Industries........................37
Resilience.............................................................................38
Safety I and Safety II...........................................................39

vii
viii ◾ Contents

Standardisation....................................................................40
Human Factors....................................................................41
Shifting from ‘ One Size Fits All’ to an Intelligent
Approach to Risk................................................................43
Suggested Reading............................................................. 44
5 The Right Culture for Safety..................................45
The Just Culture..................................................................45
Human Error.......................................................................49
Risky Behaviour..................................................................50
Reckless Behaviour.............................................................52
Suggested Reading..............................................................54
6 Learning or Counting from Incidents.....................55
Incident Reporting..............................................................55
Learning from Incident Reporting......................................59
Performance Management..................................................62
Quality of Reports.............................................................. 64
The Truth........................................................................... 64
What Can Be Done Differently for Incident Reporting?....65
7 Relegated to the Back Office..................................69
Risk Management and Incident Investigation....................69
Incident Investigation..........................................................71
Suggested Reading..............................................................74
8 The Impact on Front-Line Workers.........................75
Reflective Observation........................................................75
Bob’ s Story......................................................................... 77
Kimberley’ s Story................................................................79
Richie’ s Story.......................................................................82
Suggested Reading..............................................................87
9 The Implementation Challenge...............................89
Just Do It.............................................................................89
Seven Steps.........................................................................92
Vincristine Error..................................................................93
To Checklist or Not to Checklist........................................97
Suggested Reading............................................................100
 Contents ◾ ix

10 Implementation: The Way Forward...................... 101

What Can We Do Differently for Implementation?.......... 101
Factors That Hinder and Help..........................................103
Suggested Reading............................................................107
11 The Next Fifteen Years and Beyond.....................109
Not Alone..........................................................................109
How Did We Get Here?.................................................... 116
12 Sign Up to Safety.................................................. 119
Creating a New Movement............................................... 119
What Have We Learnt So Far?..........................................126
13 Enlightenment......................................................131
Profound Simplicity........................................................... 131
Our Throughline...............................................................133
Our Solution for Change Is Conversations...................133
14 An Evolving Concept.............................................139
Good Conversations..........................................................139
A Variety of Methodologies: The World Café Story......... 141
Methods Used to Date for Patient Safety Conversations..... 145
Factors That Hinder a Good Conversation...................... 147
Suggested Reading............................................................ 152
15 Facilitated Conversations...................................... 153
Facilitated Conversations to Narrow the
Implementation Gap......................................................... 153
Trio Methodology.............................................................. 154
Quad Methodology........................................................... 159
Fishbowl Methodology..................................................... 159
Small Group Conversations.............................................. 161
Large Group Conversations.............................................. 161
What We Have Learnt.......................................................163
Conclusion................................................................... 167
References and Further Reading................................. 171
Index........................................................................... 181
Preface

Everything we do should be about keeping patients as safe

as we can, and the vast majority of healthcare is provided
safely and effectively. However, just like any high-risk industry,
things can and do go wrong.
I have worked for the last two decades of my career in the
field of patient safety, and despite efforts across the globe,
progress towards safer healthcare has been slow and in many
areas lasting change has yet to be realised. Don Berwick
(2015) says that if you are climbing a mountain and you find
an impasse, don’ t sit there waiting for the situation to change.
If you stay, it will almost definitely lead to your demise.
However, you also can’ t try to break your way through – it
will likely be impossible to do that. The answer is to forget
that people may look down on you for failing, forget that it
may damage your self-esteem and reputation. There is no
shame in saying you are defeated. What we all need to do in
that situation is to find another way. Climb down, look back
at what we now know, look at all the evidence around us and
plot the next path. By doing that, we have already learnt one
valuable lesson about the route we will not be taking. So in
order for us to achieve patient safety, I think we need to look
at all our previous efforts that meant we didn’ t quite get there;
we reached an impasse. Look at all the evidence we have
around us, and plot a new path.

xi
xii ◾ Preface

Stopping or doing things in a very different way always

sounds like such a big deal. It sounds like something that
should be approached with awe and done once or twice in
a lifetime. We fear it will make us look stupid. I would argue
that rethinking patient safety is a very wise thing to do. I am
someone who needs more out of a career than a job. I need to
feel as if everything I do is in sync with my strong value sys-
tems. Accordingly, I have chosen a career that has become my
life – to support a quest to do something meaningful, that of
improving the safety of patient care. I will not be content until
we have plotted the next path, rapidly started to climb and, if
possible, ascended further than we ever have before.
Rethinking Patient Safety is a culmination of the learning
to date. It provides insight from myself and others on why we
have not achieved the anticipated or desired outcomes. It then
makes the case for how we need to rethink and redesign fun-
damental aspects of the current approach to patient safety, but
also provides the reader with a potential way forward – the
profoundly simple method of facilitated safety conversations.
This book is for all the patient safety mountain climbers
who are willing to take that journey towards something mean-
ingful. People who are new to the subject and those who have
made a few ascents already: all I hope is that it helps you with
a few steps towards the top and that you enjoy it along the
way.

Suzette Woodward
Acknowledgements

This book is thanks to all those who taught me so much;

those who dedicate their careers to improving the safety of
patient care. Thanks in particular to those who don’ t want
to wait a moment and are eager to change the world around
them: Shelly Jeffcott, Carl Macrae, Charles Vincent, Rene
Amalberti, Don Berwick and Eric Hollnagel, to name a few.
Particular thanks to Scott Morrish, who has moved and moti-
vated me in equal measure.
To those I have worked with over the 35 years of my
career, thank you. I have worked with the most astonish-
ing people, none more so than the most joyous team any-
one could have to work alongside – the Sign up to Safety
team, a wonderful, inspiring group of people: Dane Wiig, Cat
Harrison, Hannah Thompson, Adam Mohammed, Catherine
Ede, Jane Reid, Owen Bennett, Anna Babic, David Naylor and
Sarah Garrett. The final two chapters are very much down to
their brilliance – I just get to be the scribe.
Finally, this book is dedicated to Bradley, without whom
there would be no book. You have been a constant source
of inspiration, ideas and knowledge and have been there for
me every step of the way. You are in every beat of my heart.
Thank you.

xiii
Introduction

I believe we can change the world if we start listen-

ing to one another again.  
Margaret Wheatley
2009

Healthcare has been transformed over the centuries – it is

now extremely complex, and in turn has become stressful,
pressured and increasingly faster-paced. Time in healthcare
has come to be one of the most precious resources. Along the
way, we have lost the very essence of what we were trying to
do in those early transformative years.
Healthcare, as an industry, is no different from any other
high-risk industry; the very people who are treated and cared
for by the industry are also at risk of harm. Harm that is
caused by the treatment or care provided, as opposed to harm
caused by the natural course of the patient’ s original illness
or condition. The field of patient safety has grown out of this
knowledge and seeks to figure out why harm happens and
what we can do to minimise it happening as well as minimis-
ing its effect.
Over the last two decades, in particular, significant efforts
have been made to learn as much as we can about the sys-
tem, the way in which human beings make errors and mis-
takes and how the system could be set up to help humans be
safer. We have focused predominantly on hospital care and

xv
xvi ◾ Introduction

interventions that reduce harm, topic by topic. We have also

focused on capturing significant amounts of data in the hope
that these data will tell us where we should prioritise our
efforts. However, this cacophony of mostly top-down interven-
tions has led to people feeling drowned by instruction. In par-
ticular, people have got fed up with change, fed up with new
interventions surpassing the others, fed up with moving on
to something new before something has finished. There have
been a variety of solutions: interventions, research, improve-
ment projects, innovative products, tons of guidance, stan-
dards and national initiatives. Some were initially borrowed
from other high-risk industries (such as aviation or nuclear
power); others, as the science grew, were specifically devel-
oped by and for healthcare. This whole approach has tired
people out, turned them off. People are also fed up of being
told what to do. Change only happens when everyday people
want it to, not when someone decides they have to. People are
also becoming increasingly isolated and polarised from each
other.
Our efforts, though, have been a touch random – we give
the impression that we don’ t quite know where to start or
what to focus on when. We have also not consolidated our
actions in that we have moved from one thing to another and
then another. Successes are there, but it feels like there are
many more failures. As a result, patients are still being harmed
unnecessarily. As you read this sentence, someone will have
been given the wrong medication, been misdiagnosed, con-
tracted an infection or fallen out of bed. The efforts over the
last two decades to improve patient safety do not seem to
have made many inroads and the same things are still hap-
pening now as they were over 20 years ago. We have not yet
created a comprehensive, systematic approach to patient safety.
We need to rethink patient safety. If we were to make a
fresh start, what would that look like? I would argue that we
need to go back to the fundamentals. Ask ourselves some dif-
ficult questions, the kind of questions that you can, in fact, ask
 Introduction ◾ xvii

after you have tested interventions or ideas and assumptions.

So while we may be disappointed in our efforts so far, per-
haps it is only through these experiences that we can finally
see what we might want to do or where we now should be
focusing. Experiential learning is the very best form of learn-
ing. Therefore, this is a brilliant time to rethink patient safety,
learning from and building on our collective experiences
across the field of patient safety over the last two decades.
Experiential learning focuses on the learning process for
the individual through observation and interaction as opposed
to reading from a book. Thus, one makes discoveries and
experiments with first-hand knowledge instead of hearing or
reading about others’ experiences. Kolb (1984) talks about
moving from concrete experience to reflective observation and
then abstract conceptualisation, which leads to active experi-
mentation. This book explores our concrete experiences over
the last two decades and provides my own personal reflective
observations as well as those of others who have also worked
in the field of patient safety during this time. Reflection is a
crucial part of the experiential learning process. The book
also explores a particular concept to consider for the future
and shares the story of Sign up to Safety, which is experi-
menting with this concept to provide people with concrete
experiences.
The final part of the book sets out the case for the pro-
foundly simple concept of wanting people to talk to each
other about what they know about keeping patients safer. To
paraphrase Margaret Wheatley, I believe that we can change
the world of safety if we start listening to one another again.
Listening to another human being starts to create a relation-
ship, starts to help us understand them more. Listening means
we hear someone else’ s point of view rather than forcing our
own onto others. We move away from our judgments and
assumptions towards curiosity. This means we start to learn
more about what could be safer, what could or should be
changed. The reason why I believe this so fervently is that ‘ not
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