Textbook of Patient

Safety and Clinical

Risk Management
Liam Donaldson
Walter Ricciardi
Susan Sheridan
Riccardo Tartaglia
Editors

123
Textbook of Patient Safety
and Clinical Risk Management
Liam Donaldson  •  Walter Ricciardi
Susan Sheridan • Riccardo Tartaglia
Editors

Textbook of Patient
Safety and Clinical Risk
Management
Editors
Liam Donaldson Walter Ricciardi
London School of Hygiene and Tropical Department of Hygiene
Medicine and Public Health
London Catholic University of the Sacred Heart
UK Rome, Italy

Susan Sheridan Riccardo Tartaglia

The Society to Improve Italian Network for Safety in Healthcare
Diagnosis in Medicine Florence, Italy
Evanston, IL
USA

This book is an open access publication.

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https://doi.org/10.1007/978-3-030-59403-9

© The Editor(s) (if applicable) and The Author(s) 2021

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Foreword

As a member of the 17th legislature of the Italian Parliament, I was Speaker

for the Chamber of Deputies for the establishment of Law 24/2017 on care
safety and professional responsibility in health matters. It is a great pleasure
for me to present this publication because it is the result of the valuable work
of many colleagues all over the world. Together, we have animated the cul-
tural debate and fostered a consolidated and professional network of “clinical
risk managers” aimed at improving the quality of care in health services.
With this goal in mind, I founded the “Fondazione Italia in Salute” in
2018, at a time when the sustainability of our Healthcare System seemed to
be at risk for various factors, in the face of new health needs. The Foundation
chose to promote this book because it is consistent with its mission: to sup-
port and strengthen the protection of the right to health and the culture of
error prevention through public initiatives, medical-scientific and technical-
legal research, national and international networking activities with the aim
of establishing a system of recognition and validation of Clinical Practice
Guidelines in Italy.
In this book, you will find interesting observations and professional expe-
rience provided not only by senior experts but also by medical post-graduates
from 30 foreign countries who participated in the First International Meeting
“Patient Safety for New Medical Generation” held in Florence on September
3, 2018. The dialogue between senior experts and post-graduates in medicine
and nursing sciences is always useful; the surprising participation in this
meeting allowed the WHO to present the point of view of the younger genera-
tions of doctors on the safety of care. It is no coincidence that “teamwork
training” is the cross-cutting theme of all chapters of this book: it is important
to overcome the often still too individualistic view of hospital work.
This publication therefore becomes an important educational tool, particu-
larly for young colleagues, to broaden their knowledge of clinical risk and the
importance of the human factor in healthcare. In fact, “clinical risk manage-
ment” has only recently been included as a subject of study in medical degree
courses; some years ago, the WHO published some important documents to
guide training in care safety.
I believe that having a culture of patient safety is fundamental, and that the
change in the professional behaviours becomes effective when knowledge is
shared and risk awareness is instilled in all healthcare professionals. To this
end, we need to start training new generations of professionals, certainly
more open to change, and to promote a culture of care safety.

v
vi Foreword

I would like to thank all the authors of this book because I believe that
their excellent work will be very important for the future of international
health. Special thanks to Liam Donaldson, Walter Ricciardi, Susan Sheridan
and Riccardo Tartaglia for their willingness to produce this book. They repre-
sent all the stakeholders in the health security system: Liam, our institutions,
Walter, our universities, Susan, our citizens and Riccardo, our health
workers.
Enjoy your reading!

Federico Gelli
Fondazione Italia in Salute
Rome, Italy
Preface

Despite the extensive attention and public commitments towards patient

safety over the last two decades, levels of avoidable harm in healthcare around
the world remain unacceptably high.
By creating a book with broad scope and clear descriptions of the key
concepts and thinking in patient safety, we have aimed to connect with a
much wider readership than those with a professional or academic interest in
the subject.
We have not limited ourselves to theoretical models or risk management
methodologies. We have aimed to address safety in various medical special-
ties. For example there is a discussion of the causation and solutions in condi-
tions such as infantile cerebral palsy; today in many health systems this has a
high human and economic cost, some of which are preventable.
We have also dealt with how the structure, culture and leadership of
healthcare organizations can determine how many patients suffer avoidable
harm and how safe they and their families should feel when putting their trust
in  local services. Safety problems relating to non-technical skills are also
discussed; this is a topic of great importance but under-represented in medical
and nursing educational and training curricula.
Any assessment of the prospects for creating much safer healthcare sys-
tems and health facilities everywhere will be bound to conclude that it will be
a long journey. A clear consequence of this is that it cannot be entirely
achieved by the current group of senior patient safety leaders. Their succes-
sors need to be grown, mentored and inspired to take up the mantle of future
leadership as well as guiding those in day-to-day clinical practice where harm
is generated but where it can also be prevented.
That is why this new book has embraced the next generation of health
professionals with such warmth and enthusiasm. The idea to write it came as
a result of an international meeting on patient safety for young doctors held
in Florence, Italy, in 2018. Such doctors came from over 40 countries.
Representatives from that meeting have been involved in the chapters in Part
III of the book.
The book was conceived and commissioned in a pre-pandemic time, but
by the time it was coming near completion COVID-19 was the dominant
feature of health and healthcare across the world. This has only served to
heighten awareness of patient safety as the pandemic has swept across conti-
nents and led to seriously ill patients threatening to overwhelm acute care

vii
viii Preface

facilities and care homes in many countries. We have added a chapter that
summarizes the safety recommendations developed by the International
Society for Quality in Health Care in collaboration with the Italian Network
for Safety in Healthcare.
It is encouraging also to see that World Patient Safety Day 2020 had as its
theme health worker safety, which, of course, is closely intertwined with
patient safety.
We are grateful for the support of the Fondazione Italia in Salute (Healthy
Italy Foundation) to allow this text to be open access in order to be available
to the greatest number of interested people. We hope to see it in the hands of
young health professionals everywhere, thus giving it a global reach into the
next generation of patient safety clinical leaders and practitioners.
We express our deep gratitude to the authors for their work. We also thank
those many friends and colleagues who have made themselves available to
review the chapters from a technical and linguistic point of view.
We dedicate our work on this book to the memories of all those patients
and families who have suffered or died through avoidable harm in their care.
It is on the foundation of a safer future for all patients, everywhere in the
world, that the goal of universal health coverage should be built.

London, UK Liam Donaldson
Rome, Italy Walter Ricciardi
Evanston, USA Susan Sheridan
Florence, Italy Riccardo Tartaglia
Acknowledgements

The volume editors wish to thank the following colleagues and friends for the
chapters review and for their collaboration to the book preparation:

–– Sebastiano Bagnara, Psychologist, Florence, Italy

–– Luigi Bertinato, Istituto Superiore di Sanità, Rome, Italy
–– Gianni Biancofiore, Intensive care, University of Pisa, Italy
–– Stefano Canitano, Radiology, San Camillo de Lellis Rieti, Italy
–– Claudio Cricelli, Primary care, Italian Society General Medicine, Italy
–– Alessandro Dell’Erba, Forensic Medicine University of Bari, Italy
–– Davide Ferorelli, Forensic Medicine University of Bari, Italy
–– Alessandra De Palma, Forensic Medicine, IRCS AOU, Bologna
–– Enrico Desideri, Public Health, Fondazione Innovazione e Sicurezza delle
Cure, Rome, Italy
–– Vittorio Fineschi, Forensic Medicine, University La Sapienza, Rome, Italy
–– Paola Frati, Forensic Medicine, University La Sapienza, Rome, Italy
–– Georgia Libera Finstad,  Psychological sciences and techniques, Rome,
Italy
–– Maurizio Hazan, Lawyer, Milan, Italy
–– Roberto Nardi, Internal Medicine, Bologna, Italy
–– Patrizia Olmi, Radiotherapist, Florence, Italy
–– Maria Pia Ruggeri, Emergency Medicine,  Azienda Ospedaliera San
Giovanni-Addolorata-Britannico, Rome, Italy
–– Anna Maria Marconi, Gynaecologist, University of Milan, Italy
–– Chiara Seghieri, Statistic, School of Advanced Study Pisa, Italy
–– Andrea Silenzi, General Directorate for Health Prevention, Ministry of
Health, Rome

The volume editors also wish to express their thanks for the linguistic revi-
sion to:

–– Roland Bauman
–– Liisa Dollinger
–– Lucrezia Romano

ix
Contents

Part I Introduction

1 Guidelines and Safety Practices for Improving

Patient Safety������������������������������������������������������������������������������������   3
Walter Ricciardi and Fidelia Cascini
2 Brief Story of a Clinical Risk Manager������������������������������������������  19
Riccardo Tartaglia
3 Human Error and Patient Safety ��������������������������������������������������  29
Helen Higham and Charles Vincent
4 Looking to the Future����������������������������������������������������������������������  45
Peter Lachman
5 Safer Care: Shaping the Future������������������������������������������������������  53
Liam Donaldson
6 Patients for Patient Safety ��������������������������������������������������������������  67
Susan Sheridan, Heather Sherman, Allison Kooijman,
Evangelina Vazquez, Katrine Kirk, Nagwa Metwally,
and Flavia Cardinali
7 Human Factors and Ergonomics in Health Care
and Patient Safety from the Perspective
of Medical Residents������������������������������������������������������������������������  81
Pascale Carayon, Peter Kleinschmidt, Bat-­Zion Hose,
and Megan Salwei

Part II Background

8 Patient Safety in the World ������������������������������������������������������������  93

Neelam Dhingra-Kumar, Silvio Brusaferro, and Luca Arnoldo
9 Infection Prevention and Control ��������������������������������������������������  99
Anna L. Costa, Gaetano Pierpaolo Privitera, Giorgio Tulli,
and Giulio Toccafondi
10 The Patient Journey������������������������������������������������������������������������ 117
Elena Beleffi, Paola Mosconi, and Susan Sheridan

xi
xii Contents

11 Adverse Event Investigation and Risk Assessment ���������������������� 129

Tommaso Bellandi, Adriana Romani-Vidal, Paulo Sousa,
and Michela Tanzini
12 From Theory to Real-World Integration:
Implementation Science and Beyond �������������������������������������������� 143
Giulia Dagliana, Sara Albolino, Zewdie Mulissa,
Jonathan Davy, and Andrew Todd

Part III Patient Safety in the Main Clinical Specialties

13 Intensive Care and Anesthesiology������������������������������������������������ 161

S. Damiani, M. Bendinelli, and Stefano Romagnoli
14 Safe Surgery Saves Lives ���������������������������������������������������������������� 177
Francesco Venneri, Lawrence B. Brown, Francesca Cammelli,
and Elliott R. Haut
15 Emergency Department Clinical Risk ������������������������������������������ 189
Riccardo Pini, Maria Luisa Ralli,
and Saravanakumar Shanmugam
16 Obstetric Safety Patient������������������������������������������������������������������ 205
Antonio Ragusa, Shin Ushiro, Alessandro Svelato,
Noemi Strambi, and Mariarosaria Di Tommaso
17 Patient Safety in Internal Medicine������������������������������������������������ 213
Micaela La Regina, Alessandra Vecchié, Aldo Bonaventura,
and Domenico Prisco
18 Risks in Oncology and Radiation Therapy������������������������������������ 253
Adriano Marcolongo, Glauco Cristofaro, Aldo Mariotto,
Maurizio Mascarin, and Fabio Puglisi
19 Patient Safety in Orthopedics and Traumatology������������������������ 275
Guido Barneschi, Francesco Raspanti, and Rodolfo Capanna
20 Patient Safety and Risk Management in Mental Health�������������� 287
Alessandro Cuomo, Despoina Koukouna,
Lorenzo Macchiarini, and Andrea Fagiolini
21 Patient Safety in Pediatrics ������������������������������������������������������������ 299
Sara Albolino, Marco De Luca, and Antonino Morabito
22 Patient Safety in Radiology ������������������������������������������������������������ 309
Mahdieh Montazeran, Davide Caramella, and Mansoor Fatehi
23 Organ Donor Risk Stratification in Italy�������������������������������������� 319
Adriano Peris, Jessica Bronzoni, Sonia Meli, Juri Ducci,
Erjon Rreka, Davide Ghinolfi, Emanuele Balzano,
Fabio Melandro, and Paolo De Simone
24 Patient Safety in Laboratory Medicine������������������������������������������ 325
Mario Plebani, Ada Aita, and Laura Sciacovelli
Contents xiii

25 Patient Safety in Ophthalmology���������������������������������������������������� 339

Myrta Lippera, Jacques Bijon, Chiara Eandi,
and Gianni Virgili

Part IV Healthcare Organization

26 Community and Primary Care������������������������������������������������������ 365

Elisabetta Alti and Alessandro Mereu
27 Complexity Science as a Frame for Understanding the
Management and Delivery of High Quality and Safer Care�������� 375
Jeffrey Braithwaite, Louise A. Ellis, Kate Churruca,
Janet C. Long, Peter Hibbert, and Robyn Clay-Williams
28 Measuring Clinical Workflow to Improve
Quality and Safety��������������������������������������������������������������������������� 393
Michela Tanzini, Johanna I. Westbrook, Stefano Guidi,
Neroli Sunderland, and Mirela Prgomet
29 Shiftwork Organization������������������������������������������������������������������ 403
Giovanni Costa, Eleonora Tommasi, Leonardo Giovannini,
and Nicola Mucci
30 Non-technical Skills in Healthcare ������������������������������������������������ 413
Stavros Prineas, Kathleen Mosier, Claus Mirko,
and Stefano Guicciardi
31 Medication Safety���������������������������������������������������������������������������� 435
Hooi Cheng Soon, Pierangelo Geppetti, Chiara Lupi,
and Boon Phiaw Kho
32 Digital Technology and Usability and Ergonomics
of Medical Devices���������������������������������������������������������������������������� 455
Francesco Ranzani and Oronzo Parlangeli
33 Lessons Learned from the Japan Obstetric Compensation
System for Cerebral Palsy: A Novel System of Data
Aggregation, Investigation, Amelioration, and No-Fault
Compensation���������������������������������������������������������������������������������� 465
Shin Ushiro, Antonio Ragusa, and Riccardo Tartaglia
34 Coping with the COVID-19 Pandemic: Roles
and Responsibilities for Preparedness ������������������������������������������ 485
Michela Tanzini, Elisa Romano, Aldo Bonaventura,
Alessandra Vecchié, and Micaela La Regina
 Part I
Introduction
 Guidelines and Safety Practices
for Improving Patient Safety 1
Walter Ricciardi and Fidelia Cascini

1.1 Introduction Existing knowledge of patient safety essen-

tially covers the nosography of threats and causes
Actions to improve patient safety have  shown of patient harm, as opposed to possible evidence-­
widely varying degrees of effectiveness. based solutions that can (a) prevent risks, (b)
Usually hospitals are focused on the occurrence address healthcare incidents, and (c) which can
of adverse events and the level of adversity to the be compared. This means that etiology, patho-
patient in the contexts of insurance premiums and genesis, and observations of safety issues in clin-
the costs of malpractice. Furthermore, even risk ical departments, and, more broadly in healthcare
management units within hospitals focus on these organizations, are often investigated while proven
factors, when comparing the performance of solutions to patient safety issues are rarely dis-
departments or wards. However, for the improve- cussed. To give an appropriate analogy, it is like
ment of patient safety in clinical practice, a dif- saying that there are many papers that have exam-
ferent approach is required, in which the ined perioperative complications, type of surger-
prevention of patient harm and effectiveness of ies, and patient characteristics. However, no
clinical actions is standardized and assessed on research is available on how the occurrence of
the basis of scientific evidence. these complications have been managed in differ-
Recommendations that have been translated ent settings according to organizational and
into guidelines are the best possible evidence-­ human factors.
based solutions to clinical practice issues. It is essential that healthcare professionals
However, it appears that there are very few clini- acquire proficiency in producing evidence that
cal guidelines focused on patient safety, particu- can be used for making improvements to patient’s
larly in the risk management sector. Furthermore, safety and managing the risks of adverse events.
when using clinical guidelines for quality and To successfully achieve this goal, the first step is
safety improvement, practices often seem to for them to have a clear idea of what guidelines
diverge. Higher quality and safer clinical practice and practices are. Definitions of these terms will
are consequently difficult to achieve, share, and be the content of the first section of this chapter.
promote. Once these concepts have been introduced, the
second section will show the current picture
W. Ricciardi · F. Cascini (*) regarding patient safety and why a greater num-
Section of Hygiene and Public Health, Università ber of valuable clinical guidelines are needed.
Cattolica del Sacro Cuore, Rome, Italy The third section will then consider possible
e-mail: [email protected]; solutions, lessons to apply in practice, and will
[email protected]

© The Author(s) 2021 3

L. Donaldson et al. (eds.), Textbook of Patient Safety and Clinical Risk Management,
https://doi.org/10.1007/978-3-030-59403-9_1
4 W. Ricciardi and F. Cascini

explain how to prepare and update a guideline. The U.S.  National Guideline Clearinghouse
The challenges we are facing along with the lim- (NGC) of the Agency for Healthcare Research
its of the current guidelines will be considered at and Quality (AHRQ) also uses the definition of
the end, which will assist in managing patient clinical practice guidelines developed by the
safety in future. IOM, stating that “clinical practice guidelines are
statements that include recommendations
intended to optimize patient care that are
1.2  he Need to Understand
T informed by a systematic review of evidence and
Guidelines Before Improving an assessment of the benefits and harms of alter-
Safety native care options” [3].
The British National Institute for Health and
The World Health Organization (WHO) regards Care Excellence (NICE) stresses scientific evi-
guidelines as tools to help people to make deci- dence as the basis of guidelines. It states: “NICE
sions and particularly  emphasize the concept of guidelines make evidence-based recommenda-
choosing from a range of interventions or mea- tions on a wide range of topics, from preventing
sures. A WHO guideline is any document devel- and managing specific conditions, improving
oped by the World Health Organization containing health, and managing medicines in different set-
recommendations for clinical practice or public tings, to providing social care and support to
health policy. A recommendation tells the intended adults and children, safe staffing, and planning
end-user of the guideline what he or she can or broader services and interventions to improve the
should do in specific situations to achieve the best health of communities” [4].
health outcomes possible, individually or collec- The Italian National Center for Clinical
tively. It offers a choice of different interventions Excellence (CNEC) that is responsible for the
or measures that are intended to have a positive National Guidelines System (SNLG) uses essen-
impact on health and explains their implications tially the same definition as NICE, stressing the
for the use of resources. Recommendations help importance of evidence-based medicine as the
the user of the guideline make informed decisions foundation of recommendations in guidelines.
on whether to undertake specific interventions or The recent report on healthcare quality
clinical tests, or  if they should implement wider improvement published by the European
public health measures, as well as where and when Observatory on Health Systems and Policies [5]
to do so. Recommendations also help the user to reiterates that clinical guidelines focus on how to
select and prioritize across a range of potential approach patients with defined healthcare prob-
interventions [1]. lems, either throughout the entire care process or
With a greater emphasis on clinical practice, in specific clinical situations. As such, they can
the U.S.  Institute of Medicine (IOM) defines be considered as a tool to inform healthcare
guidelines as “statements that include recom- delivery, with a specific focus on the clinical
mendations, intended to optimize patient care, components, in the context of medical practice as
that are informed by a systematic review of evi- an applied science. Clinical guidelines have the
dence and an assessment of the benefits and potential to reduce unwarranted practice varia-
harms of alternative care options” [2]. This defi- tion and enhance translation of research into
nition emphasizes that the foundation of a guide- practice; a well-developed guideline which is
line is a systematic review of the scientific also well implemented will help improve patient
evidence bearing on a clinical issue. The strength outcomes by optimizing the process of care [6,
of the evidence leads the clinical decision-­making 7].
process through a set of recommendations. These From the perspective of international accredi-
concern the benefits and harms of alternative care tation societies such as Joint Commission
options and address how patients should be man- International (JCI), guidelines that help health-
aged, everything else being equal. care organizations to improve performance and
1  Guidelines and Safety Practices for Improving Patient Safety 5

outcomes are part of the foundation of processes intervention whose effectiveness has already
aimed at reaching the goal of safe and high-­ been established. This concept is widely appli-
quality care [8]. JCI maintains that clinical prac- cable in health care, from patient safety to public
tice guidelines are truly major and effective tools health, including the quality of care. In fact, a
in the practice of delivering evidence-based med- best practice is based on evidence from up-to-­
icine to achieve more effective patient outcomes date research and it has the added value of incor-
and safer care. These guidelines, which must be porating experience acquired in real-life
used in all JCI accreditation programs, can settings.
achieve their maximum potential when they are A best practice provides tangible solutions as
both well developed and effectively introduced the most effective process or method to achieve a
into clinical practice. specific objective, with results that are shareable.
All of  the definitions mentioned are consis- As a consequence, the practice can then become
tent. Guidelines are not presented as a substitute a model. Some organizations are working on cre-
for the advice of a physician or other knowledge- ating best practice models, in particular, on
able healthcare professionals or providers. They selecting techniques or methodologies that have
are tools describing recommended courses of been proven to be reliable in achieving desired
intervention whose key elements are the best results through consolidated and updated experi-
available scientific evidence and actions accord- ence and research. The British Medical Journal
ing to this evidence. The goal is the promotion of (BMJ), for example, funds a service (available at
health and consequently, the quality and safety of https://bestpractice.bmj.com/info/) that collects
care. However, it is also desirable for profession- the latest evidence-based information to support
als to share within the scientific community the professional decisions and brings together regu-
results from using clinical practice guidelines in larly updated research evidence and the knowl-
the context of valuable, real-world experience to edge of international experts. According to the
inform safety interventions. Professionals are BMJ, its best practice tool is “a clinical decision
expected to share their current practice to help support tool that offers a step-by-step approach to
them apply guidelines to real-life situations and help manage patient diagnosis, prognosis, treat-
also to improve guidelines in the light of that ment and prevention.”
experience.
Ensuring the quality of healthcare services
and making improvements to patient safety 1.3  he Current Patient Safety
T
require that evidence-based recommendations Picture and the Demand
from guidelines, and their application in the form for Guidelines
of practical interventions (best practices), always
function as synergetic tools. Nevertheless, there In most healthcare settings worldwide, patient
is no consensus on what constitutes practice-­ safety data is data on the absence of patient
based evidence (which is what emerges from rou- safety. On the last patient safety day (September
tine hospital activities) and what metrics can be 17, 2019), WHO announced, “Patient safety is a
used to ensure the quality of this evidence. serious global public health concern. It is esti-
Healthcare interventions that have been shown to mated that there is a 1 in 3 million risk of dying
produce desirable outcomes and that are suitable while travelling by airplane. In comparison, the
for adaptation to other settings can be called risk of patient death occurring due to a prevent-
“best practices.” A best practice is “an interven- able medical accident, while receiving health
tion that has shown evidence of effectiveness in a care, is estimated to be 1  in 300” [10]. WHO’s
particular setting and is likely to be replicable to message is based on facts found in studies and
other situations” [9]. Moreover, a best practice is statistics. These inform us that one in every 10
not a synonym of a good practice or, simply, of a patients is harmed while receiving hospital care
practice: it is an already existing and selected (amounting to nearly 50% of adverse events
6 W. Ricciardi and F. Cascini

considered preventable) [11]. Further, the occur- Additional measures to implement safety in
rence of adverse events due to unsafe care is one practices should be mandatory, such as tools that
of the 10 leading causes of death and disability are mainly evidence-based as well as the education
across the world [12]. The report of the WHO of and outreach to providers and patients, and the
continues with the following findings [13]: widespread use of hospital-based electronic health
records. Nevertheless, the practical implementa-
• Four out of every 10 patients are harmed in tion of evidence-based research to treat unsafe situ-
primary and outpatient (ambulatory) health ations remains uncertain. One paradigm case is that
care, with up to 80% of the harm considered to of the healthcare-related infections where, although
have been preventable. a standardized evidence-­based approach to patient
• Patient harm may account for more than 6% of safety seems accessible and extremely useful in
hospital bed days and more than 7 million this field (e.g., hand hygiene guidelines) [22],
admissions. WHO recently reported [10] that the numbers of
• The most detrimental errors are related to healthcare-­associated infections remain high,
diagnosis, prescription, and the use of affecting up to 10 out of every 100 hospitalized
medicines. patients, and that a large proportion were prevent-
able [23–25]. A recent systematic review [26] also
Moreover, there are other serious conse- observed that 35–55% of healthcare-associated
quences. The WHO report also included the fol- infections were preventable. This suggests that
lowing criticisms concerning the “health status” there remains much to be desired in terms of imple-
of patient safety worldwide: the costs from unsafe mentation of evidence-based best practices.
medication practices or medication errors [14, Further, the levels of reductions in such infections
15] and from delayed diagnosis [16, 17], the attributable to the implementation of multifaceted,
costs of treating the effects of patient harm, the evidence-based interventions are in line with previ-
complications from surgery that cause more than ous estimates [27, 28].
1 million patient deaths every year [18], and the Even in high-income countries where a high
inappropriate or unskilled use of medical radia- level of adherence to current recommendations is
tion leading to health hazards to both patients and expected, and despite the existence of evidence-­
staff [19]. based strategies, a further reduction in the occur-
Approaches to improve patient safety have rence of these infections of 30–50% is achievable
already been suggested. Evidence-based care [26]. In reality, a large discrepancy is emerging
positively affects healthcare practice and patient between the intention to effect change by employ-
outcomes. For example, the United States Agency ing standard operating procedures and the accu-
for Healthcare Research and Quality (AHRQ) rate implementation of such practices in daily
[20] stated that the chances of a patient receiving practice [29]. Great potential exists to further
safer care when entering a hospital have decrease hospital-acquired infection rates in a
increased; an estimated 87,000 fewer patients variety of settings. Relevant factors in the success
died from hospital-acquired conditions between of such programs include the study design, base-
2010 and 2014 in the USA. This not only repre- line infection rates and type of infection [30].
sents a major improvement in patient safety, but Other factors such as global aging trends and
also resulted in estimated savings of $19.8 bil- comorbidity are likely to require additional
lion. The US Agency reminded noted  that hard efforts to reduce the risk of infections while med-
work to reduce undesired outcomes had been per- ical innovations may also reduce this risk due to
formed by everyone from front-line staff to the emergence of less invasive techniques (e.g.,
nurses, physicians, and hospital administrators. minimally invasive surgery or noninvasive
Further, theoretical financial savings from safety ventilation).
improvement and patient involvement were iden- Suggestions for how to address safety
tified by WHO [13, 21]. improvement in health care can be derived from a
1  Guidelines and Safety Practices for Improving Patient Safety 7

literature review of evaluations of interventions. and the related literature differ from the other
The negative impact of failing to improve quality biomedical research in two major respects. First,
and safety in health care is a public health issue evaluations of specific interventions often fail to
[9]. Instead of simply moving onto the next new meet basic standards for the conduct and report-
paradigm, it is worth considering what deficien- ing of research. Second, and more fundamentally,
cies exist in the literature and how these might be the choices of particular interventions lack com-
rectified [31]. pelling theories that can predict their success or
be applied to specific features during their devel-
opment. Methodological shortcomings in the
1.4 Implementing the Research quality improvement research literature include
on Patient Safety to Improve basic problems with the design and analysis of
Clinical Practice the interventions as well as poor reporting of the
results.
Evidence-based medicine is the use of the best In light  of this, a recent review [34] high-
available evidence to inform decisions about the lighted that delivering improvements in the qual-
care of individual patients [32]. This means that ity and safety of health care remains an
clinical care choices undergo rigorous evaluation international challenge. In recent years, quality
instead of having their effectiveness presumed on improvement methods such as plan-do-study-act
the basis of subjective experience or arguments (PDSA) cycles have been used in an attempt to
relating to the etiopathogenesis of diseases. drive such improvements. This method is widely
Despite this, it has been noticed [31] that imple- used in healthcare improvement however there
mentation efforts typically proceed on the basis are  little overarching evaluations of how it is
of intuition, anecdotal stories of success, or stud- applied. PDSA cycles can be used to structure the
ies that exhibit little of the methodological process of change iteratively, either as a stand-
sophistication seen in the research that estab- alone method or as part of a range of quality
lished the intervention’s benefit, even after mul- improvement approaches, such as the Model for
tiple rigorously designed and well-conducted Improvement (MFI), Total Quality Management,
clinical trials have established the benefit of a Continuous QI, Lean, Six Sigma or Quality
particular care process. Improvement Collaboratives [35–37].
Systematic reviews of the evidence and clini- Despite the increased use of quality improve-
cal practice guidelines that synthesize studies ment methods, the evidence base for their effec-
addressing important clinical decisions have been tiveness is poor and unsubstantiated [31, 38, 39].
underestimated in clinical practice. A variety of PDSA cycles are often a central component of
factors have prevented clinicians from acquiring quality improvement initiatives; however, few
evidence in a reliable and timely fashion. Such formal objective evaluations of their effective-
evidence would include factors that have been the ness or application have been carried out [40].
object of only limited study so far. Other ele- Some PDSA approaches have been demonstrated
ments of implementing evidence-based medicine to result in significant improvements in care and
that have been glossed over include the follow- patient outcomes [41] while others have demon-
ing: disagreement with the content of guidelines, strated no improvements at all [42–44]. Thus,
which could quickly become out of date or have evidence of effective quality improvement inter-
wide variations in methodological quality; the ventions remains mixed, with literature conclud-
personal characteristics of providers, for exam- ing that quality improvement interventions are
ple, their resistance to perceived infringements only effective in specific settings and are used as
on physician autonomy; and logistical or finan- “single-bullet” interventions that cannot deliver
cial barriers [33]. consistent improvements. Conversely, effective
It has also been noted [31] that research into interventions need to be complex and multifac-
quality improvement (including patient safety) eted [45–47] and developed iteratively to adapt to
8 W. Ricciardi and F. Cascini

the local context and respond to unforeseen odology adopted and the conclusions of the
obstacles and unintended effects [48, 49]. trial. This kind of research is needed to produce
Finding effective quality improvement meth- informative, reliable, and evidence-based con-
ods to support iterative development to test and clusions that ultimately lead to, from a wider
evaluate interventions in clinical care is essential point of view, a change of perspective. To be
for the delivery of high-quality and high-value precise, the aim is to switch the focus from the
care in a financially constrained environment. statistics on patient injuries, damages, and
However, in the field of quality and safety claims, to data derived from clinical trials.
improvement, strategies for implementing Ultimately, the purpose of collecting this data is
evidence-­ based medicine require an evidence to propose actions and solutions to deal with the
base of their own, unlike in other medical disci- lack of safety in healthcare organizations, and
plines [50]. Progress in researching quality medical treatments.
improvement requires an understanding of the Empirically-derived models are needed to
factors driving provider and organizational inform decisions to select specific implementa-
change. Moreover, possible elements affecting tion strategies, based on clinical features of the
the results of research when implemented in quality target, organizational or social context,
practice, such as organizational factors and and relevant attitudes and beliefs of providers and
human features related to both professionals and patients. These models thereby contribute to
patients, have to be considered. Additionally, improvements to quality and the value of the ser-
research into patient safety improvement and its vices delivered, and so help to reduce dramatic
implementation requires looking at the health- statistics that can overshadow the vision of a
care system as a whole, including professionals, safer healthcare system. It must be noted that
patients, and features of facilities. although the iterative development of change
Once an intervention to improve safety has (PDSA cycle) is the most validated model to
been developed, the next step should be a pilot improve quality and safety, no single quality
study to confirm that it works or, in other words, improvement tool can absolutely be considered
a Phase I of clinical studies [51]. The pilot study the best. Preferences depend on the skills of pro-
should start from a study design that includes the fessionals and the type of setting which
formulation of the hypothesis, the method of means choosing one method over another for an
sampling the population involved in the study, organization can be difficult.
the choice of and correlations between dependent The choice of the model is an important deci-
and independent variables, and the analysis and sion as it can involve serious risks and costly con-
reporting of results. It is important to ensure that sequences for healthcare organizations. The
the interpretations and explanations of the effi- integration and adaptation of different models to
cacy and value of interventions adopted to man- healthcare settings is generally preferable to
age specific patient safety issues are shareable. choosing only one model. However, the problem
Researchers and clinicians working on is that no formal criteria for evaluating the appli-
patient safety improvement should take into cation or reporting of PDSA cycles currently
consideration the following: how to carry out exist. It is only in recent years, through SQUIRE
this particular type of research; if it is correct to guidelines, that frameworks for publication that
consider just a sample or the whole population explicitly describe PDSA applications have been
of patients; what techniques to use in data col- developed [52, 53]. Such frameworks are neces-
lection and observation processes; and how to sary to support and assess the effective applica-
describe the data. All of these elements are tion of PDSA cycles and to increase their
essential to support the hypothesis of the study, legitimacy as a scientific method for
and to give credibility to both the research meth- improvement.
1  Guidelines and Safety Practices for Improving Patient Safety 9

1.5 Working Towards Producing Checklist, which is available on the internet

Guidelines That Improve (https://cebgrade.mcmaster.ca/guidecheck.html).
Safety Practices It is divided into 18 steps as follows [57].

As documents that synthesize current evidence 1. Organization, budget, planning, and train-
on how to most effectively organize and deliver ing. These involve outlining a detailed plan
health services for a given condition [54], guide- describing what is feasible, how it will be
lines inform healthcare decision-making and can achieved, and what resources will be required
serve as a basis for policy, planning, evaluation, to produce and use the guideline. The plan
and quality improvement. “Working towards pro- should define a specific completion date and
ducing guidelines that improve safety practices” be expressed in formal, measurable terms.
means developing structured processes to write, 2. Priority setting. This refers to the identifica-
update, and apply guidelines. The most important tion, balancing, and ranking of priorities by
element to take into account is the methodology. stakeholders. Priority setting ensures that
Consequently, it is fundamental to have a plan resources and attention are devoted to those
that is divided into different steps and that can be general areas where healthcare recommenda-
summarized as a checklist. In fact, a checklist for tions will provide the greatest benefit to the
developing guidelines should contain a compre- population, jurisdiction, or country, e.g.,
hensive list of topics and items outlining the prac- chronic obstructive pulmonary disease, dia-
tical steps to consider. The checklist is intended betes, cardiovascular disease, cancer, and
for use by guideline developers to plan and track prevention. A priority-setting approach needs
the process of guideline development and to help to contribute to future plans while respond-
ensure that no key steps are missed. Following ing to existing, potentially difficult
the steps outlined in the checklist ensures that circumstances.
key items are covered and increases the likeli- 3. Guideline group membership. This defines
hood of the guideline achieving higher scores who is involved and  in what capacity, how
when evaluated with credibility assessment tools. the members are selected, and in which steps
Checklists for developing guidelines can be com- of the development of the guidelines each of
bined with guideline credibility assessment tools them will participate.
like AGREE1 (Appraisal of Guidelines for 4. Establishing guideline group processes. This
Research and Evaluation) [55] and other tools defines the steps to be followed, how those
that may reflect standards established by the involved will interact, and how decisions will
Guidelines International Network2 (GIN) [56] or be made.
Institute of Medicine (IOM). 5. Identifying target audience and topic selec-
One easy-to-use and reliable checklist is the tion. This involves defining the potential
GIN-McMaster Guideline Development users or beneficiaries of the guidelines and
defining the topics to be covered in the guide-
The AGREE (Appraisal of Guidelines for Research and
1  line (e.g., the diagnosis of chronic obstruc-
Evaluation) Collaboration developed the most commonly tive pulmonary disease).
used instrument to assess the quality of a guideline. The 6. Beneficiary and other stakeholder involve-
instrument comprises 23 criteria grouped in six domains
ment. This describes how relevant people or
(addressed by the AGREE II): scope and purpose; stake-
holder involvement; rigor of development; clarity and pre- groups who are not necessarily members of
sentation; applicability; and editorial independence. the panel (e.g., as the beneficiaries or users)
The work of the Guidelines International Network (http://
2 
will be affected by the guidelines and
www.g-i-n.net/) promotes the dissemination of guideline- involved in their development.
related content and provides an exchange platform for
guideline developers and users. Further, the GIN provides
7. Conflict of interest considerations. This
reporting guidance for guideline-based performance mea- focuses on defining and managing the poten-
surement tools. tial divergence between an individual’s
10 W. Ricciardi and F. Cascini

interests and his or her professional obliga- lining inclusion and exclusion criteria based
tions. These considerations lead to questions on types of evidence (e.g., rigorous research
about whether actions or decisions are moti- or anecdotes), study designs, characteristics
vated by gain, such as financial, academic of the population, interventions, and com-
advancement, clinical revenue streams, or parators. It also covers deciding how the evi-
community standing. Financial, intellectual, dence will be identified and obtained, which
or other relationships that may affect an should not be limited to evidence about val-
individual’s or organization’s ability to ues and preferences, local data and resources.
approach a scientific question with an open 11. Summarizing evidence and considering
mind are included. additional information. This focuses on pre-
8. Question generation. This focuses on defin- senting evidence in a synthetic format (e.g.,
ing key questions the recommendations tables or brief narratives) to facilitate the
should address using the PICO (patient/ development and understanding of recom-
problem, intervention, comparison, out- mendations. It also involves identifying and
come) framework, including the detailed considering additional information relevant
population, intervention (including diagnos- to the question under consideration.
tic tests and strategies), and outcomes that 12. Judging quality, strength, or certainty of a
will be relevant in decision-making (e.g., in body of evidence. This consists of assessing
chronic obstructive pulmonary disease, the confidence one can place in the evidence
should test A or treatments B, C, D, or E be obtained by transparently evaluating the
used?). research (individual- and group studies) and
9. Considering the importance of outcomes and other evidence applying structured
interventions, values, preferences, and approaches. This may include, but is not lim-
advantages. This includes integrating how ited to, evidence about baseline risk or bur-
those affected by recommendations should den of disease, the importance of outcomes
assess the possible consequences into the and interventions, values, preferences, bene-
process of developing guidelines. These con- fits and drawbacks, use of resources (e.g.,
siderations can include: (a) patient, caregiver, finance), estimates of effects, and accuracy
and healthcare provider knowledge, atti- of diagnostic tests.
tudes, expectations, moral and ethical values, 13. Developing recommendations and determin-
and beliefs; (b) patient goals for life and ing their strength. Developing recommenda-
health; (c) prior experience with the inter- tions involves the use of a structured
vention and the condition; (d) symptoms analytical framework and a transparent and
experienced, e.g., breathlessness, pain, dys- systematic process to integrate the factors
pnea, weight loss; (e) preferences relating to that influence a recommendation.
and importance of desirable and undesirable Determining the strength of the recommen-
outcomes; (f) perceived impact of the condi- dations refers to judgments about how confi-
tion or interventions on quality of life, well-­ dent a guideline panel is that the
being, or satisfaction; (g) interactions implementation of a recommendation will
between the work of implementing the inter- exert a greater number of desirable conse-
vention, the intervention itself, and patient quences than undesirable ones.
experiences; (h) preferences for alternative 14. Wording of recommendations and of consid-
courses of action; and finally, (i) preferences erations about implementation, feasibility,
relating to communication content and and equity. This refers to choosing syntax
styles, information and involvement in and formulations that facilitate the under-
decision-­making and care. standing and implementation of the recom-
10. Deciding what evidence to include and mendations, accounting for the views of the
searching for evidence. This focuses on out- guideline panel.
1  Guidelines and Safety Practices for Improving Patient Safety 11

15. Reporting and peer review. Reporting refers [61]. Essentially, GRADE classifies recommen-
to how a guideline will be made public (e.g., dations as “strong” when a specific, recom-
print, online). Peer review refers to how the mended intervention or management strategy
guideline document will be reviewed before would be chosen, on reasonable grounds, by a
its publication and how it can be assessed majority of patients, clinicians, or policymak-
(e.g., for errors), both internally and exter- ers in all care scenarios. In contrast, such recom-
nally, by stakeholders who were not mem- mendations would be classified as “weak” when
bers of the guideline development group. there is a reasonable range of choices, reflecting
16. Dissemination and implementation. This the following possible factors: limited evidence
focuses on strategies to make relevant groups quality, uncertain benefit-harm ratios, uncertainty
aware of the guidelines and to enhance their regarding treatment effects, questionable cost-­
uptake (e.g., publications and tools such as effectiveness, or variability in values and prefer-
mobile applications). ences [62]. Further, the GRADE
17. Evaluation and use. This refers to formal and evidence-­to-­decision framework helps guideline
informal strategies that allow the evaluation developers to structure their process and evalua-
of (a) the guidelines as a process and prod- tion of available evidence [59]. Nonetheless, a
uct; (b) their use or uptake, or both; and (c) trade-off between methodological rigor and prag-
their impact and whether or not they will matism is required [63, 64].
lead to improvements in patient or popula- Concerning the issue of applying recommen-
tion health or other consequences. dations to individual patients, it has been observed
18. Updating. This refers to how and when a that practices from guidelines vary considerably
guideline will require revision because of and translating guidelines into practice can fail to
changes in the evidence or other factors that close gaps that have been identified, both in the
influence the recommendations. scope and the follow-up of interventions [65].
Education for professionals and/or patients is a
All the above-mentioned steps are believed to good strategy to ensure the implementation of
optimize the development and implementation of guidelines. Nonetheless, another substantial
guidelines. However, two tough questions on influence on the ability to implement guidelines
guidelines persist, namely [8]: is how their implementation has already been
built into the guideline development process. The
(a) Is there enough evidence to make planning of implementation provides a set of
recommendations? concrete, actionable steps to take during the
(b) How should we apply recommendations to implementation phase [66, 67]. The central ele-
individual patients? ments of successful implementation approaches
appear in: their target-oriented dissemination,
With respect to the evidence to make recom- education and training, social interaction, deci-
mendations, guideline development tools have, sion support systems and routine procedures,
since their inception in 2003, increas- thereby  tailoring implementation strategies to
ingly  included the GRADE approach [58–60]. settings and target groups [68]. To assist guide-
The Grading of Recommendations Assessment, line developers regarding implementation, a tool
Development and Evaluation (GRADE) approach with context-specific implementability features
was created by the eponymous working group for the whole guideline process has been devel-
(www.gradeworkinggroup.org), which is a col- oped [69].
laborative project, consisting mainly of method- Further, clinicians must balance the risks and
ologists and clinicians. It provides a framework benefits of any guideline recommendation for an
for assessing the quality (or “certainty”) of the individual patient and consider that patient’s
evidence supporting, inter alia, guideline recom- preferences. If the patient does not adhere to care
mendations and therefore their resulting strength recommendations, health benefits will not be
12 W. Ricciardi and F. Cascini

maximized or perhaps even realized. Clinical modernization, for example, by introducing arti-
decisions should be based on guideline recom- ficial intelligence into health care. Thus, beyond
mendations, but all decisions must be individual- the methodological quality of the guideline itself,
ized according to a patient’s risk-benefit ratio there are many relevant aspects which represent
and  incorporate patient preferences through challenges or limits to take into account regard-
shared decision-making. Clinician leadership in ing guidelines and their applicability.
quality improvement efforts and administrative The first challenge is to improve the effective-
support are key drivers of quality and safety ness of a guideline—especially regarding how it
improvement through  care-integrated tools and improves the safety of care—while also focusing
aligned incentives aimed at achieving meaningful on patient-centeredness; this principle consists of
guideline implementation. (a) properly taking into account the needs and
One of the most prominent developments in preferences of patients and of their caregivers and
the area of guideline implementation in recent (b) supporting professionals in improving their
years has been the increased utilization of infor- practice. These dimensions are fundamental to the
mation technologies to facilitate: (a) push mecha- delivery of care and to patient outcomes as well
nisms for guideline adherence, such as decision [73–75]. Patient-centeredness constitutes a more
support components integrated into clinical man- recent focus of the discussion around the develop-
agement software, for example, alerts, reminders, ment and use of guidelines [76]. Guidelines can
or routine procedures [70]; (b) the use of guide- facilitate patient education, engagement, and
lines at the bedside, available on, for example, shared decision-making, thus assuring that indi-
mobile guideline apps; (c) the faster and poten- vidual patient values are balanced against the
tially real-time updating of individual guideline desired outcomes, which are embedded in the tri-
recommendations as new evidence emerges, for als that form the basis of guideline recommenda-
example, by adding “living guidelines” [71, 72]. tions. Different modalities of patient involvement
Observational data is necessary to describe cur- exist in different contexts. The two most studied
rent health provision and its quality, pinpoint ones are (a) patient group representatives, who are
potential patient groups that are adequately cov- sometimes involved in the guideline development
ered by guideline recommendations, and identify process and (b) guideline documents, which are
gaps and issues to be resolved by clinical increasingly produced in different formats for
research. This data is also vital for identifying practitioners and patients [77–81].
late onset treatment harms and drug safety issues. Another challenge is related to the speed with
which medical knowledge progresses and the
pace of knowledge production at the  primary
1.6  he Challenges of Improving
T research level. Guideline recommendations are
Safety and the Current expected to be kept up to date  but a relatively
Limits of Guidelines recent, comprehensive review of this issue [82],
concluded that 1 in 5 recommendations is out of
Guidelines are expected to be focused on broad date 3 years after being launched and that longer
and complex topics, on developing standards to updating intervals are potentially too long.
guide healthcare organizations, on providing best Additionally, the development and updating of
practice recommendations for patient care, and clinical guidelines represents a challenge because
on informing the clinical decision-making of of the speed and resources required for producing
health professionals. Successfully incorporating and especially updating them. Approaches that
all of these factors into features of guidelines is can result in efficient and potentially real-time
particularly difficult in today’s age of complexity updating of guideline recommendations as new
and multimorbidity. This is an age which is also evidence emerges have been discussed, particu-
characterized by the desire for personalized med- larly in the form of living systematic reviews and
icine and the ambition to push the frontiers of living guidelines [71, 83–85].
1  Guidelines and Safety Practices for Improving Patient Safety 13

With regard to limitations, there are different tices [5] clearly demonstrates how divergent
aspects to consider. Maybe the most restrictive guideline practices can be, especially when
limitation regards the evaluation of the costs of viewed as strategies for the improvement of
the guideline development process, compared healthcare quality. The context-specific nature of
with the effectiveness of guidelines, once they guidelines persists, despite their adaptability to
are implemented. This limitation particu- the practices of different countries. In the past, the
larly  relates to the use (or under-use) of cost-­ quality of clinical guidelines was narrowly defined
effectiveness analyses as a part of the development according to how closely recommendations were
process of clinical guidelines and their related linked to scientific and clinical evidence [92];
challenges or opportunities [86]. A comprehen- however more recently, researchers have explic-
sive cost-effectiveness analysis should cover the itly addressed the question of whether guidelines
costs of the development and of the guideline dis- should be systematically pilot-tested in care deliv-
semination/implementation processes, and the ery settings before being finalized [93].
change in the effectiveness of health service by Switching the focus to how guidelines are
putting the guideline into practice. However, data implemented, newer studies have shown mixed
on the costs of guideline development is scarce results regarding the effect of guidelines on out-
and, given the vast variability of settings and comes but established a clear link between imple-
practices, likely not generalizable [87]. As has mentation modalities and patient outcomes
been already pointed out [88], only 27% of 200 [94–97]. Barriers to the adoption of or adherence
studies on guideline implementation strategies to guidelines by clinicians have been discussed in
(of which only 11 were from Europe) had some the literature. Substantial gaps were found in the
data on cost and only 4 (2%) provided data on evidence on the effectiveness of implementation
development and implementation. Most of the interventions, especially regarding clinical out-
relevant studies only partially accounted for the comes, cost-effectiveness, and contributory con-
costs incurred in the process of guideline produc- textual issues [98]. Barriers included time
tion. In some contexts, active implementation constraints, limited staffing resources, clinician
seemed to require a substantial upfront invest- skepticism, clinician knowledge of guidelines,
ment compared to general dissemination prac- and the age of the clinician. The characteristics of
tices. Furthermore, the results regarding guidelines, such as format, resources, and end-­
optimized processes of care and improved patient user involvement, were identified as facilitating
outcomes were not sufficient to render them cost-­ factors, along with stakeholder involvement,
effective [89, 90]. leadership support, and organizational culture
Another relevant limitation is that the concept (including multidisciplinary teams and electronic
of a guideline-based quality indicator framework guidelines systems).
has so far been inadequately elaborated, despite Beyond challenges and limits, there is the
the fact that performance measurement sustains issue of editorial independence in clinical guide-
the relationship between clinical guidelines and line development. Implementing guideline rec-
healthcare data. More and more guideline groups ommendations that have been created in irregular
have developed quality indicators along with sets conditions is not only ethically questionable but
of recommendations [91]. Usually,  these indica- may also endanger quality of care, as the content
tors are primarily intended as general perfor- may not actually reflect best available evidence.
mance measures. However, a closer look at To give an example of irregular conditions, an
measurement results can provide insights into the international survey of 29 institutions involved in
extent to which practice reflects guideline recom- clinical guideline development found variability
mendations. In other words, the indicators inform in the content and accessibility of conflict of
us on the extent of guideline adherence, and con- interest policies; some institutions did not have
sequently feed into how they are shaped. publicly available policies and, of the policies
Moreover, an overview of country-specific prac- available, several did not clearly report critical
14 W. Ricciardi and F. Cascini

steps in obtaining, managing, and communicat- should in turn be rigorously implemented in

ing disclosure of relationships of interest [99]. clinical practice as the best safety practice.
While financial conflicts of interest seem to have 2. More scientific research into healthcare qual-
been adequately disclosed in the most rigorously ity and safety improvement is needed, the
developed guidelines, active management of results and effectiveness of which should be
existing conflicts of interest has lagged behind shared across the scientific community
[100–103]. Beyond measures to address direct worldwide.
financial conflicts of interest, the management of 3. To face the challenges of a changing health-
indirect conflicts of interest is also important in care sector in today’s age of multi-­morbidities,
guideline development. Such indirect conflicts tutors, researchers, caregivers, and patients
can include issues related to academic advance- should work together to address the current
ment, clinical revenue streams, community limits of clinical guidelines.
standing, and engagement in academic activities
that foster an attachment to a specific point of
view [104]. Ensuring that guidelines are devel-
oped on the basis of robust consensus processes References
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 Brief Story of a Clinical Risk
Manager 2
Riccardo Tartaglia

2.1 Introduction Italian services no longer occupy the top posi-

tions [3].
This chapter briefly recounts the story of some- In the current Italian context, Tuscany is one
one who worked as a clinical risk manager of a of the regions with the best indicators of quality
regional health service for 16 years since his of care, along with some northern regions.
appointment as director of a regional center for Let us briefly describe the context in which
clinical risk management and patient safety. the story takes place. Tuscany is located in the
The purpose of this chapter is to provide a tes- center of Italy and covers an area of approxi-
timony of one of the first international experi- mately 23,000  km2, 67% of which is hilly. It is
ences of safety management in a public health home to about 3.7 million inhabitants and a
service. It does not claim to speak to a particular health service with 33 acute care hospitals of
type of profession but aims to relate an experi- which three are university hospitals in Florence,
ence in which some will recognize themselves, Pisa, and Siena. Every year about 550,000 people
others will be able to find advice, and others will are admitted to public hospitals in Tuscany. Of
be able to understand the differences with the them, 1500 patients annually claim compensa-
health reality in which they operate. It may also tion for alleged harm resulting from treatment
be useful in order to define the “clinical risk man- received, but only 40% of these citizens will be
ager,” a new professional figure that has now awarded compensation, amounting to a total of
entered the scene in our hospitals. about 40–50 million euros a year.
This story takes place in Italy, a country that, Healthcare is mainly public and adopts the
according to international indicators [1] and the tax-financed Beveridge model. The cost of public
World Health Organization (WHO) [2], has a health service is around 7.4 billion euros a year,
fairly good health service but with very strong with a per capita quota of 1981 euros, compared
variability between the northern and southern to a national average of 1888 euros per capita [4].
regions.
Unfortunately, the economic crisis has wors-
ened the situation and, in terms of quality of care, 2.2 The Start

In 1989, Scally and Donaldson [5] promoted

R. Tartaglia (*) clinical risk management in the field of clinical
Italian Network for Safety in Healthcare, governance and, in 1999, the “To err is human”
Florence, Italy report was published [6]. At the same time, James
e-mail: [email protected]

© The Author(s) 2021 19

L. Donaldson et al. (eds.), Textbook of Patient Safety and Clinical Risk Management,
https://doi.org/10.1007/978-3-030-59403-9_2
20 R. Tartaglia

Reason travelled the world making his “Swiss experience and made a report for an important
Cheese model” known globally [7], while Charles television program in which she showed how
Vincent published “Clinical risk management: doctors discussed their mistakes. In the broad-
enhancing patient safety” in 2001 [8]. cast, you are presented with a slightly darkened
It was precisely in 2001 when the medical hospital room in which a group of doctors, almost
director of my hospital brought me the book by like some secret sect, was discussing adverse
Charles Vincent and asked me to take charge of events. I believe it was the first significant event
health safety. The reason he proposed this role to audit or confessional meeting filmed for televi-
me stemmed from my position as manager of a sion in Italy.
structure that dealt with ergonomics and the At that time, the alderman of the Regional
human factor in the field of occupational safety, a Health Service, who participated in the James
relevant issue for clinical risk management. Reason conference, understood the importance
I started working on this topic with some of the subject and launched the establishment of
young people from my unit and we grew passion- a regional center that would coordinate all the
ate about it. I was the only doctor, a specialist in activities for the management of clinical risk and
occupational health and public health, surrounded patient safety in Tuscan hospitals. The aim of this
by an industrial designer and experts in commu- center would have been the promotion of a cul-
nication sciences and sociology. The medical ture of safety, the reporting of adverse events, and
director was highly interested in patient safety. learning from adverse events—in a word, our
We no longer dealt with the latter, except for mission. It was announced publicly that one mil-
aspects related to occupational stress and lion euros had been raised for the establishment
burnout. of a regional patient safety center.
We started presenting the Swiss Cheese Model
to fellow doctors and nurses, inviting them to
promote incident reporting. We stressed the 2.3  he Evolution of the Patient
T
importance of a “no blame” culture to the direc- Safety System
tors of units, doctors, and nurses, with the sup-
port of health management, but our moment of After the James Reason conference, the Tuscany
fame came in 2002 when we invited James region decided to invest one million euros to
Reason to Florence. In an auditorium full of doc- organize a center for clinical risk management in
tors and nurses, people began to talk about medi- an Italian region of 3.7 million inhabitants and 33
cal errors, a subject that up until then was acute care hospitals.
untouchable, almost unthinkable. Since forensic I was then in charge of running this center
medicine was dominant at that time, we wanted with a budget of only around 600,000 euros for
to make it clear that our aim was not the pursuit personnel management (the announced invest-
of professional responsibility (i.e., negligence, ment was therefore somewhat reduced). I of
inexperience, and imprudence), but to learn from course turned to the operators I already had in my
error. old ergonomic group, 8 young and brilliant tech-
Reason concluded his presentation by stating nicians chosen on the basis of multidisciplinary
that “we cannot change the human being which skills, and overcame numerous bureaucratic
by nature is fallible, but we can change working problems that represented the greatest initial
conditions in an attempt to prevent and intercept operational difficulty—bureaucracy is the great-
errors before they cause an adverse event.” He est enemy of safety.
also told us that we would still have accidents and It is difficult for many to understand the
that we should learn to manage them, even from importance of other professional figures in
the point of view of communication. healthcare than traditional doctors, nurses, obste-
A journalist from the most important national tricians, etc. In Italian healthcare, according to an
television network heard about our Florentine ancient and outdated conception of professional
2  Brief Story of a Clinical Risk Manager 21

skills, there is a health area (i.e., traditional health A scientific committee consisting of the best
professions) and a technical-administrative area medical specialists and nurses in the health ser-
(i.e., statisticians, computer scientists, sociolo- vice had the function of supporting the center in
gists, communicators, jurists, engineers). These all the more strictly clinical assistance-related
areas rarely interact and are often separated both aspects which we would encounter during sig-
physically (e.g., across different buildings) and nificant events audit, mortality and morbidity
intellectually. Teamwork is exclusively linked to meetings, and the promotion of safety practices.
common interest in a few topics and to the net- Working in this multidisciplinary context has
working skills of individual operators. been culturally enriching for clinicians and
In my opinion, the acquisition of knowledge is nurses as well as other professional figures,
difficult when people do not work together. This resulting in a continual exchange of knowledge
also applies to primary care and hospital profes- that has favored professional growth.
sionals. Opportunities and moments for exchange The headquarters were planned to reside in a
are needed at least weekly. building of the most important Tuscan hospital.
I must say that in recent years clinical risk
management has brought many professionals
closer to each other, due to its multidisciplinary 2.4  he Network of Clinical Risk
T
approach. For example, IT professionals are now Manager
involved in the ergonomics and usability of com-
puterized medical records, which are frequently After implementing staff training, a network of
sources of error, while psychologists and com- professionals (one in each hospital) was needed
munication experts are involved in the analysis of in order to organize the activity, develop a report-
adverse events. Each of my collaborators had ing and learning system, and create a risk man-
solid training in ergonomics and the human fac- agement system.
tor, acquired through master degree programs We asked the general managers of each hospi-
and academic courses, and therefore skills in tal to designate a point person for clinical risk
accident analysis, communication, highly reli- and patient safety. In the beginning, we did not
able organization, and resilience. If I had imme- expect specifically trained professional figures
diately opted for a team of doctors and nurses, the but professionals from biomedical, psychosocial,
budget would probably not have been enough and and technical fields with good reputation, credi-
we would have spent much more time recruiting bility, and standing among other clinicians and
new staff. Furthermore, for a healthcare organi- health professionals. Some choices proved to be
zation, a doctor contractually costs more than a right and others not, which is normal.
sociologist or industrial designer. Over time, I noticed a certain vulnerability
As a matter of fact, over time the skills avail- of this new professional figure. Although safety
able to the team proved both useful and valid for is the duty of every healthcare worker and can-
our work. A center that deals with clinical risk not be delegated to a single professional, the
and the complexity of the causes of accidents risk manager often becomes a scapegoat for
must include professionals that come from vari- many problems. For this reason, they are some-
ous disciplinary areas besides health [9]. With times replaced not on the basis of professional
regard to communication problems (which often ability and merit but of loyalty to the general
cause accidents), organizational problems, and manager.
problems associated with the interactions with The selected professionals followed a manda-
biomedical, ergonomic, and legal equipment, the tory university course involving over one hun-
professionals in our team were much better pre- dred hours of training and a 1-week internship in
pared than other professionals in their own disci- a hospital risk management service. Subsequently,
pline, precisely thanks to the specific training in in almost all hospitals, the professionals obtained
human factor and risk management. a risk management unit with collaborators.
22 R. Tartaglia

For each hospital unit, other doctors or nurses, After the risk managers’ first year of work, we
usually one or two, were then identified as realized that the professionals coming from the
facilitators. clinical side performed better than those who had
The facilitators were expected to be profes- worked in health departments. The reason was
sionals, usually doctors and nurses, who, in addi- essentially that the clinical professionals had a
tion to performing their daily work, should have closer relationship with the structures we sought
had hours dedicated to promoting clinical audits to improve.
and mortality and morbidity meetings following Furthermore, the managers of quality and
adverse events, unsafe actions, and missed accreditation structures and the managers of clin-
accidents. ical risk continued to exist as separate entities.
The two roles coincided only in rare cases. For
this reason, we identified in each hospital a clini-
2.5 Training and Instruction cal risk manager (CRM) and a patient safety
manager (PSM), thus differentiating the func-
The training of our gladiators, numbering about tions [11].
30, took place in collaboration with one of the In Italy as well as internationally, care safety
most prestigious Italian universities, the and quality management and accreditation have
Sant’Anna School of Advanced Studies in Pisa. had different stories. While clinical risk manage-
The course was very hands-on, including lectures ment was born in more recent times and has
by experts on the subject and many exercises on attracted the immediate interest of professionals,
clinical cases of adverse events and the imple- quality management and accreditation have never
mentation of safety practices. However, the most fascinated clinicians because of the excessive
beautiful experience of this course was the bureaucracy and the occasional distance of the
1-week internship at various international procedures proposed by clinical practice from
hospitals. real problems.
We took our gladiators to numerous hospitals Regarding our two professional roles, the
to show them what actions could be taken to CRM is a professional who works on the clinical
improve patient safety. We visited the hospitals of side and is entrusted with risk management in a
many cities (such as Berlin, London, Boston, department, while the PSM is a doctor, nurse, or
Chicago, Copenhagen, Paris, Valencia, and non-healthcare professional who operates among
Amsterdam), comparing the different risk man- the health management staff. Figure 2.1 summa-
agement models adopted. This experience was rizes the differences between these two lines of
very useful for the planning of our work [10]. operation and the professional figures involved.
What stood out was that, in most of the hospi- Today, following specific training and experi-
tals we visited, clinical risk management was ence, we can provide a professional certification
entrusted to nurses. The doctors were mainly
involved in mortality and morbidity meetings and
in research projects almost always conducted in ANTICIPATION CONTROL
multidisciplinary teams.
In our country, risk management is entrusted
to medical personnel with the support of senior ASSESSMENT ANALYSIS

nurses, albeit with some rare exceptions. I believe

that with regard to competences, it is always nec- IDENTIFICATION MEASUREMENT
essary to evaluate the context of reference and the
Clinicians line Managerial line
functions of units, research, or clinical health. Clinical risk manager Patient safety manager
The training topics have gradually changed over
time, adapting to emerging needs and to the Fig. 2.1  Activities of clinical risk manager and patient
transformation of the role of the professional. safety manager
2  Brief Story of a Clinical Risk Manager 23

for this role (clinical risk manager/patient safety On February 20, 2007, about 2 years after we
manager) in order to enhance their skills and started implementing our risk management sys-
offer more guarantees to insurance system. tem, the first important event happened. We had a
The training has substantially contributed to serious sentinel event that had great media cover-
the definition of a risk management model that age at the national and international levels. It
we have theorized and put into practice over happened in the field of transplant surgery, an
about 15 years. area that we mistakenly thought to be fairly safe
because it was under the control of national
supervisory bodies. Furthermore, it involved an
2.6 Adverse Events analytical laboratory in which the attention to the
procedures of the accreditation and quality sys-
Some of the studies we have conducted in our tem is very high. The case involved the transplan-
regional health service [12, 13] did not show tation of two kidneys and a liver from an
higher rates of adverse events compared to other HIV-positive donor to three patients awaiting
research carried out with similar methodology. transplantation [16].
Similarly, the claims rate is average compared The event had great resonance but the center,
with other Italian regions. at least in the initial phase, was absolutely not
Our reporting and learning system has clearly involved in the analysis of what happened. The
lowered the levels of confidentiality thus expos- case was managed by political leaders only and
ing our health service to the media. Where there exclusively at a communicative level. It was
is no transparency, it is difficult for serious acci- announced that the cause was human error of an
dents to emerge as everything is managed confi- operator who had erroneously transcribed the
dentially. If significant event audits or mortality machine data for serological examinations in the
and morbidity meetings are organized, news report.
leaks out more easily. Nevertheless, the number Instead of a culture of learning based on the
of adverse events reported by our operators discussion of organizational problems that can
through our reporting system is always much determine the occurrence of significant events, a
lower than expected. The expected amount, culture of guilt had prevailed. A culprit was
which is at least 4–5 times higher, was deter- immediately found; the rotten apple was removed
mined from the comparisons we have made with from the bunch.
colleagues from other countries where reporting Subsequent analyses conducted by various
systems have been operating for a longer time. national and regional committees have shown
Under-reporting had been attributable to the that in those working conditions any human
fear of judicial consequences until the first of being could have made mistakes. In this case, that
April, 2017, when the law on patient safety and human being was a good and honest biologist,
professional liability was instituted. However, in the only one to bear the blame for what had hap-
our experience the main cause of under-reporting pened. In organizing the task, the human factor
was the absence of a safety culture (i.e., “I’m not had not been taken into account. A “traditional”
used to reporting, it’s just not the way things are way of working continued to prevail in which a
done”) [14]. human being rather than a machine had to per-
The law introduced in 2017 has protected form a monotonous and repetitive job, reporting
reporting and learning systems from legal action serological examination results.
since documents produced within these systems It was therefore decided that each of these
cannot be used for judicial purposes [15]. The patients would be rewarded with a very high
development of a clinical risk management system compensation. It was a decision that served to
did not completely shelter us from serious acci- stop the controversy around the event: the
dents but it helped to deepen our understanding of news disappeared from the media in a few
clinical cases with an unexpected outcome. days.
24 R. Tartaglia

As head of clinical risk management, I was Unfortunately, some general managers were
determined to resign. After this serious event, I very far removed from the basic principles of
felt it was my duty, even if we had not yet inter- clinical risk management. They were only inter-
vened in the transplant system precisely because ested in the economic costs and the volume of
it was a sector with its own autonomy. I was activity, not value of care.
asked to investigate what had happened. The Obviously, politics has considerable weight
results of the investigation we conducted brought and responsibility in imprinting certain behaviors
about many changes, highlighting several critical in general managers. Although training has been
issues in the transplant system. Donations had introduced in management courses, it has never
increased too quickly compared to the system’s been enough to change the externally ingrained
ability to meet operational needs. behaviors nor the behaviors guided by the nature
It was one of the many cases in which I real- of the employees themselves.
ized that legal truth is not always consistent with Overall, we can affirm that some important
“true truth.” successes have been achieved. At an organiza-
With regard to sentinel events, the biggest tional level, we have been equipped for years
problem was overcoming the strong desire of with a reporting and learning system that is a
politicians and general managers to look for a credit to our organization. There has been a
culprit (culture of guilt) in order to focus their reduction in the number of accidents and falls in
attention on preventing the recurrence of such an the hospital, the latter being the most frequent
event (no-blame culture). cause of damage reports. According to third-­
When a serious accident occurs, the citizens party data, we are the Italian region with the low-
want a culprit even if the time taken by justice is est rate of maternal mortality and mortality in
much longer than that of the clinical risk man- intensive care. Attention to infections has
ager, whose first goal is to secure the hospital and increased even if their rate continues to be high.
provide psychological support for the victims of Much more could and should be done.
event, both the first victim, the patient, and the
second victim, the professional.
2.8 The Relationship
with Politics and Managers
2.7 The First Results
Politicians, obviously with some exceptions,
We had our first results when we started dissemi- have rarely shown interest in the many national
nating all the good safety practices that research and international events we have organized. I
had developed in the meantime: introduction of realized over time that the topic of patient safety
hand hygiene gels, checklists for operating the- does not excite politicians. The reason is simple:
aters, prevention of postpartum hemorrhage, pre- talking about mistakes, the criticalities of a health
vention of thromboembolic complications, system, and litigation has no electoral value. It is
bundles for the prevention of CVC infections, much more politically profitable to talk about
etc. Since, more than 30 safety practices have robotic surgery, transplants, technological inno-
been developed in collaboration with clinicians. vation, and opening up new health services. Even
The greatest difficulty was the differences in if it is clear from the data that in the last 15 years
implementation capacity, which depend little on we have saved money and above all human lives
the clinical risk manager. Much depends on the thanks to clinical risk management, politics has
environmental context and on how much impor- always preferred other topics. On the other hand,
tance the general manager gives to safety and it is true that patient safety is an electoral cam-
quality of care. The best results concerned those paign theme that can be used to denigrate the
hospitals in which management executives gave political opponent. In fact, whenever elections
great importance to the patient safety. approached, newspaper headlines about “mal-
2  Brief Story of a Clinical Risk Manager 25

practice” poured in to instrumentally demon- being administrated by regional apparatuses or

strate the inefficiency of the health service. managed by personnel employed by hospitals.
One of the critical issues that has arisen in Patient safety has never been a topic of pride
recent years is the lack of autonomy of the center for politicians even when the results were good.
with respect to political apparatus and hospital Politicians prefer to maintain an attitude of
managers. The regional bodies of clinical govern- “understatement” on this issue. There is the
ment that deal with the safety of care, such as the awareness that at any time a serious accident can
Tuscan GRC center, must have their own opera- occur and this could be exploited by the opposi-
tional and budgetary autonomy. These are tion against the current administration. It is there-
technical-­scientific bodies that cannot depend fore preferable to promote the “positive” aspects
directly on the political and administrative gov- of the health service such as the opening of a new
ernment. The model of government agencies structure, the purchase of new equipment, and the
should be adopted, guaranteeing these bodies a hiring of doctors. Although patient safety is one
third-party nature and independence, precisely of the eight domains of healthcare risk manage-
because of the importance of their role. ment [18], its real importance has not yet been
Despite the unanimous approval of a specific understood (Fig. 2.2).
request by the regional council [17], the regional Another crucial aspect involving the risk man-
executive committee has never given autonomy ager relates to the culture of guilt facilitated by
to the center. hindsight bias. Those who do not subscribe to a
As operators, we have always remained culture of safety and sometimes even great clini-
administratively dependent on the hospital from cians often fall into this trap of judging the past
which we came. This hospital was one of the based on new knowledge of the facts. In our
structures subjected to evaluation by the regional country, in the event of a serious accident, people
apparatus and therefore by our center. This obvi- immediately want a culprit even when events
ously led to a clear conflict of interests and con- may have complex causes. In some of the serious
sequent management difficulties due to the desire accidents in the health service that I investigated,
of some managers to influence the activities of the identification of a culprit and the communica-
the center. tion to the public that the cause was due to human
Currently, the Italian law for safety of care error generally reduced the clamor produced by
foresees in every Italian region the presence of the media. Stating that the problem is the respon-
centers for the management of healthcare-­ sibility of a single person and not a structural or
associated risk and patient safety. However, the organizational problem calms public opinion and
law does not provide precise indications on their is therefore a functional strategy for the system.
administrative location and level of independence. Even before knowing the facts, we start to attri-
None of these structures has total autonomy, bute the responsibility and the blame most often

Fig. 2.2  Areas of risk Technology

in healthcare
management
Cyberisk Organizational
risk/burocracy

Human
Clinical risk resourses

Economics Legal/political

Occpational
safety&health
26 R. Tartaglia

Table 2.1  Differences between human factors and forensic investigations

Type of investigation Forensic Human factors/ergonomics
Ownership Judicial Authority Clinical Governance Institution
Aim Ascertain illegal actsFinding criminals Redesign system interactions to improving safety
Approach Focus on individual performance Focus on system awareness (organizational
(contractual relationship) context)
Investigation team Police detectives, coroner, clinicians Experts in HF/E: clinicians, psychologists (team
(team leader with expertise in forensics) leader with expertise in HF/E)
Investigation Police interrogations, recorded Meetings with healthcare professionals based on
methods and tools interviews, surveillance the systemic analysis
Outcomes Preliminary investigation report with Confidential report of contributory factors and
evidence of individual culpability recommendation for improving patient safety
Time scale In keeping with forensic procedures, In keeping with healthcare organization activities
investigation, debate, and court judgment and needs (days/months)
(years)
Resulting actions Judgment in a court of law and Implementation of improvement actions and
sentencing (individual-oriented) learning-focused patient safety measures
(system-oriented)

to the individual, rarely to management, and In my experience, I have been in interesting

hardly ever to politics. situations in which we, as clinical risk operators,
I have noticed this attitude in numerous cases have investigated the same event together with
where even the most evident responsibilities of the police. Table 2.1 shows some differences that
the political-administrative system were not emerged from a careful analysis of the facts [19].
brought under scrutiny (e.g., lack of personnel, As I once heard from John Ovretveit in his
technological criticalities, training criticalities). beautiful lecture in Florence, the successful
Another important aspect is the general man- improvement of patient safety depends only 10%
agers’ understanding of the need to maintain the on the clinical risk manager and slightly more
two lines of action separate in the management of (20%) on “safety practices” which must be based
sentinel events. We have repeatedly theorized in strong scientific evidence. 40% of the success
that the first goal of a risk manager when an acci- is derived from the cultural landscape in which
dent occurs is to analyze what has happened and the practices are disseminated but, above all,
quickly introduce prevention measures to secure 60% is grounded in the climate created by the
the system. It is therefore necessary to initiate corporate establishment that favors the achieve-
clinical audits, mortality and morbidity meetings, ment of greater safety of care, rewarding and cel-
and root cause analysis. ebrating quality.
The search for responsibility is generally the
duty of the investigating judiciary or other admin-
istrative bodies whose purpose is to identify the 2.9  he Italian Law on the Safety
T
judicial and administrative responsibilities. of Care
It is therefore advisable that the risk manager
is not involved in investigations aimed at identi- Fourteen years after the birth of the center that I
fying responsibilities. It is also advisable not to directed, the Italian law on the safety of care was
make the documentation produced within the promulgated. Some important international mag-
reporting and learning systems available to law- azines have covered the contents [15, 20].
yers or judges in order to identify the responsi- The law is due to two Italian medical parlia-
bilities. Exceptions are obviously cases involving mentarians, Federico Gelli and Amedeo Bianco
malice, that is, intention to cause damage on the and it is titled “Provisions for care safety and pro-
part of the professional. fessional responsibility.” It has introduced impor-
2  Brief Story of a Clinical Risk Manager 27

tant changes which have provided strength to all ing from climate change science. BMJ Qual Saf.
2011;20(Suppl1):i73–8.
those working in the field of clinical risk 10. Nuti S, Tartaglia R, Niccolai F.  Rischio Clinico e
management. Sicurezza del Paziente. Rischio clinico e sicurezza del
It has created specific clinical risk manage- paziente. Modelli e soluzioni nel contesto internazio-
ment centers in each Italian region with the aim nale Ed. Bologna: Il Mulino; 2007.
11. Bellandi T, Albolino S, Tartaglia R, Bagnara S. Human
of collecting data on adverse events and promot- factors and ergonomics in patient safety management.
ing best safety practices. It has also protected In: Human factors and ergonomics in health care and
reporting and learning systems by preventing the patient safety. 2nd ed. Boca Raton, FL: CRC Press
use of the internally produced documents for Taylor & Francis Group; 2012. p. 671–90.
12. Tartaglia R, Albolino S, Bellandi T, Bianchini E,

judicial purposes. This law also provides specific Biggeri A, Fabbro G, Bevilacqua L, Dell’Erba
training for those who decide to become clinical A, Privitera G, Sommella L.  Adverse events and
risk managers in hospitals. The professional cer- preventable consequences: retrospective study
tification system implemented in our country is in five large Italian hospitals. Epidemiol Prev.
2012;35(3–4):151–61.
giving further value to this professional role. 13. Albolino S, Tartaglia R, Bellandi T, Bianchini E,

Finally, it has provided regulation for scientific Fabbro G, Forni S, Cernuschi G, Biggeri A. Variability
societies around the generation of guidelines and of adverse events in the public healthcare service of
recommendations for safety of care. It is not yet the Tuscany region. Intern Emerg Med. 2017; https://
doi.org/10.1007/s11739-017-1698-5.
clear whether hospitals can become “highly reli- 14. Albolino S, Tartaglia R, Bellandi T, Amicosante

able organizations” [21] but this law could con- AMV, Bianchini E, Biggeri A. Patient safety and inci-
tribute thanks to the changes it produces. dent reporting: the point of view of the Italian health-
care workers. Qual Saf Health Care. 2010;19(Suppl
3):8–12.
15. Bellandi T, Tartaglia R, Sheikh A, Donaldson L. Italy
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 Human Error and Patient Safety
3
Helen Higham and Charles Vincent

3.1 Introduction error. We also need to understand that while we

can make personal efforts to avoid errors, the
Making a serious error is one of the most stress- greatest protection will come from working in a
ful professional experiences for a doctor or for team of people who are willing to recognise
anyone in clinical practice. In other professions, errors, speak up, support each other, and protect
such as architecture or the law, serious mistakes both patients and colleagues from the conse-
can generally be remedied with an apology and quences of errors.
compensation for losses sustained. But in medi-
cine, mistakes can have serious and lifelong con-
sequences for patients and families. 3.2 What Is an Error?
Medical schools rightly encourage the highest
standards of professional practice. Doctors are In everyday life, recognising error seems quite
expected to work hard and do their best for their straightforward though admitting it may be
patients and, ideally, not make errors. It is tempt- harder. Immediate slips, such as making tea when
ing to think that only ‘bad’ or ‘lazy’ people make you meant to make coffee, are quickly recog-
mistakes and that making a serious error implies nised. Other errors may only be recognised long
a flaw in character not worthy of a serious profes- after they occur. You may only realise you pre-
sional. The reality however is that all doctors, scribed a drug incorrectly when the patient
indeed all clinicians, will make errors during returns to follow-up clinic a few weeks later with
their career and that some of them will have seri- problematic side effects from an overdose. Some
ous consequences. errors, such as missing a lung tumour on an X-ray
We cannot completely avoid errors but we can taken to investigate a potential shoulder injury,
do much to reduce them, to spot them more may only become apparent years later.
quickly and to protect patients from the worst of An important common theme running through
the consequences. However, in order to do this, all these examples is that an action is only recog-
we need to understand the nature of error and, in nised as an error after the event. Human error is a
particular, how working conditions strongly judgement made in hindsight [1]. There is no spe-
influence our behaviour and the likelihood of cial class of things we do or don’t do that we can
designate as errors; it is just that some of the
H. Higham (*) · C. Vincent things we do turn out to have undesirable or
University of Oxford, Oxford, UK unwanted consequences. This does not mean that
e-mail: [email protected]; we cannot study error or examine how our
[email protected]

© The Author(s) 2021 29

L. Donaldson et al. (eds.), Textbook of Patient Safety and Clinical Risk Management,
https://doi.org/10.1007/978-3-030-59403-9_3
30 H. Higham and C. Vincent

o­ therwise efficient brains lead us astray in some drug become dangerously high. Finally, the
circumstances, but it does suggest that there will notion of intention, and in theory at least being
not be specific cognitive mechanisms to explain able to act differently, is challenged by the fact
error that are different from those that explain that people’s behaviour is often influenced by
other human thinking and behaviour. factors, such as fatigue or peer pressure, which
Eric Hollnagel [2] points out that the term they may not be aware of and have little control
error has historically been used in three different over. So, while the working definition is reason-
senses: as a cause of something (wrong site sur- able, we should be aware of the difficulties of
gery due to human error), as the action or event applying it in practice.
itself (removing the incorrect kidney) or as the
outcome of an action (the death of a patient from
renal failure). The distinctions are not absolute in 3.3 Understanding Error
that many uses of the term involve both cause and
consequence to different degrees, but they do In his analysis of different types of error, James
have a very different emphasis. Reason [4] divides them into two broad types of
The most precise definition of error, and most error: slips and lapses, which are errors of action,
in accord with everyday usage, is one that ties it and mistakes which are, broadly speaking, errors
to observable behaviours and actions. As a work- of knowledge or planning. Reason also discusses
ing definition, John Senders [3] proposed that an violations which, as distinct from error, are inten-
error means that something has been done which: tional acts which, for one reason or another, devi-
ate from the usual or expected course of action.
• Was not desired by a set of rules or an external These psychological analyses are mainly con-
observer cerned, with failures at a particular time and
• Led the task or system outside acceptable probe the underlying mechanisms of error. There
limits is therefore not necessarily a simple correspon-
• Was not intended by the actor dence with medical errors which, as discussed
above, may refer to events happening over a
This definition of error, and other similar ones period of time. However, we will see that this
[2], imply a set of criteria for defining an error: conceptual scheme is very helpful in understand-
ing errors in clinical practice and how they some-
• First, there must be a set of rules or standards, times combine to cause harm to patients.
either explicitly defined or at least implied and
accepted in that environment
• Second, there must be some kind of failure or 3.3.1 Slips and Lapses
‘performance shortfall’
• Third, the person involved did not intend this Slips and lapses occur when a person knows what
and must, at least potentially, have been able they want to do, but the action does not turn out
to act in a different way as they intended. Slips relate to observable
actions and are associated with attentional fail-
All three of these criteria can be challenged, or ures, whereas lapses are internal events and asso-
at least prove difficult to pin down in practice. ciated with failures of memory. Slips and lapses
Much clinical medicine is inherently uncertain occur during the largely automatic performance
and there are frequently no easily applicable pro- of some routine task, usually in familiar sur-
tocols to guide treatment. In addition, the failure roundings. They are almost invariably associated
is not necessarily easy to identify; it is certainly with some form of distraction, either from the
not always clear, at least at the time, when a diag- person’s surrounding or their own preoccupation
nosis is wrong or at what point blood levels of a with something in mind.
3  Human Error and Patient Safety 31

A trainee doctor working on a surgical ward is pre- may simply be unfamiliar with the clinical pre-
scribing an antibiotic for a patient after a ward
round. Just as she opens the patient’s drug chart
sentation of a particular disease, or there may be
on the computer a nurse interrupts because he is multiple diagnostic possibilities and no clear way
concerned about a patient with very low blood of choosing between them; a surgeon may have
pressure. The doctor goes with the nurse forgetting to guess at the source of the bleeding and make
to complete the prescription. Other tasks follow
and there is a substantial delay in delivery of the
an understandable mistake in their assessment in
antibiotic and the patient becomes profoundly the face of considerable stress and uncertainty. In
septic. none of these cases, does the clinician have a
good ‘mental model’ of what is happening to
base their decisions on, still less a specific rule or
3.3.2 Mistakes procedure to follow?
In knowledge-based mistakes, the changes
Slips and lapses are errors of action; you intend encountered are not recognisable or planned for
to do something, but it does not go according to and rely on the cognitively effortful and error
plan. With mistakes, the actions may go entirely prone processes of reasoning:
as planned but the plan itself deviates from some A patient deteriorates rapidly after extubation on
adequate path towards its intended goal. Here the intensive care and the endotracheal tube cannot be
failure lies at a higher level: with the mental pro- repositioned in the usual way (via the mouth or
cesses involved in planning, formulating inten- nose). The team involved has not faced such a chal-
lenging situation before and the opportunity to site
tions, judging, and problem solving [4]. If a a surgical airway (tracheostomy) at an early stage
doctor treats someone with chest pain as if they is missed. The challenges of making decisions
have a myocardial infarction, when in fact they about the choice of airway are compounded by the
have a perforated gastric ulcer, then this is a mis- high levels of stress in this situation.
take. The intention is clear, the action corre-
sponds with the intention, but the plan was
wrong. 3.3.3 Violations
Rule-based mistakes occur when the person
already knows some rule or procedure, acquired Errors are, by definition, unintended in the sense
as the result of training or experience. Rule-based that we do not want to make errors. Violations, in
mistakes may occur through applying the wrong contrast, are deliberate deviations from safe oper-
rule, such as treating someone for influenza when ating practices, procedures, standards, or rules.
you should follow the guidelines for meningo- This is not to say that people intend that there
coccal sepsis. Alternatively, the mistake may should be a bad outcome, as when someone
occur because the procedure itself is faulty (defi- deliberately sabotages a piece of equipment; usu-
cient clinical guidelines for instance). ally, people hope that the violation of procedures
A swab is inadvertently left in a wound after sur- won’t matter on this occasion or will actually
gery because the standard operating procedure for help get the job done. Violations differ from
counting swabs is not followed properly. errors in several important ways. Whereas errors
(Misapplication of a good rule) are primarily due to our human limitations in
A patient is transferred from one site to another
with inadequate medical assistance and monitor- thinking and remembering, violations are more
ing. (Application of a bad rule: the standard oper- closely linked with attitudes, motivation, and the
ating procedure for the safe transfer of patients is work environment. The social context of viola-
poorly designed and difficult to understand, the tions is very important and understanding them,
patient is inappropriately deemed fit for low
dependency transport) and if necessary curbing them, requires attention
to the culture of the wider organisation as well as
Knowledge-based mistakes occur in novel the attitudes of the people concerned.
situations where the solution to a problem has to Reason distinguishes three types of
be worked out on the spot. For instance, a doctor violations.
32 H. Higham and C. Vincent

• A routine violation is basically cutting corners its maintenance and operation. The most obvious
for one reason or another, perhaps to save time errors and failures are usually those that are the
or simply to get on to another more urgent immediate causes of an accident, such as a train
task. driver going through a red light or a doctor pick-
• A necessary violation occurs when a person ing up the wrong syringe and injecting a fatal
flouts a rule because it seems the only way to drug.
get the job done. For example, a nurse may The immediate causes described above are the
give a drug which should be double checked result of actions, or omissions, by people at the
by another nurse, but there is no one else avail- scene. However, other factors further back in the
able. The nurse will probably give the drug, causal chain can also play a part in the genesis of
knowingly violating procedure, but hoping an accident or a serious clinical incident. These
that this is in the patient’s interest. ‘latent conditions’ lay the foundations for acci-
• Optimising violations which are for personal dents in the sense that they create the conditions
gain, sometimes just to get off work early or, in which errors and failures can occur [5]. This
more sinister, to alleviate boredom, ‘for places the operators at the sharp end in an invidi-
kicks’. Think of a trainee surgeon carrying out ous position as James Reason eloquently
a difficult operation in the middle of the night, explains:
without supervision, when the case could eas- Rather than being the instigators of an accident,
ily wait until morning. The motivation is operators tend to be the inheritors of system
partly to gain experience, to test oneself out, defects …their part is usually that of adding the
but there may be a strong element of the final garnish to a lethal brew whose ingredients
have already been long in the cooking [4]
excitement of sailing close to the wind in defi-
ance of the senior surgeon’s instructions. The organisational accident model applies this
perspective to the study and analysis of accidents
In practice, the distinction between slips, mis- in many complex industries [5]. The accident
takes, and violations is not always clear, either to sequence begins (from the left) with the negative
an observer or the person concerned. The rela- consequences of organisational processes, such
tionship between the observed behaviour, which as planning, scheduling, forecasting, design,
can be easily described, and the psychological maintenance, strategy, and policy. The latent con-
mechanism often hard to discern. Giving the ditions so created are transmitted along various
wrong drug might be a slip (attention wandered organisational and departmental pathways to the
and the doctor picked up the wrong syringe), a workplace (the operating theatre, the ward, etc.),
mistake (misunderstanding about the drug to be where they create the local conditions that pro-
given), or even a violation (deliberate over seda- mote the commission of errors and violations
tion of a difficult patient). The concepts are not (e.g. high workload or poor human–equipment
easy to put into practice, except in circumstances interfaces). Many unsafe acts are likely to be
where the action, context, and personal charac- committed, but very few of them will penetrate
teristics of those involved can be quite carefully the defences to produce damaging outcomes. The
explored. fact that engineered safety features, such as
alarms or standard procedures, can be deficient
due to latent conditions as well as active failures
3.4 Understanding the Influence is shown in Fig.  3.1 by the arrow connecting
of the Wider System organisational processes directly to defences.
The model presents the people at the sharp
Human beings have the opportunity to contribute end as the inheritors rather than as the instigators
to accidents and clinical incidents at many differ- of an accident sequence. Reason points out that
ent points in the process of production and opera- this may simply seem as if the ‘blame’ for
tion. Problems and failures may occur in the ­accidents has been shifted from the sharp end to
design, testing, implementation of a new system, the system managers. However, managers too are
3  Human Error and Patient Safety 33

Organisation Contributory factors Care Delivery Defences &

and Culture Problems Barriers

Work/ Environment Unsafe Acts

Factors

Team Factors
Management
Decisions Errors
Individual
and
(staff) Factors Incident
Organisational
Processes
Task Factors

Violations
Patient Factors

LATENT ERROR & ACTIVE

FAILURES VIOLATION FAILURES
PRODUCING
CONDITIONS

Fig. 3.1  Organisational accident model from Vincent [6]

operating in a complex environment and the At the top of the framework are patient fac-
effects of their actions are not always apparent; tors. In any clinical situation, the patient’s condi-
they are no more, and no less, to blame than those tion will have the most direct influence on
at the sharp end of the clinical environment [7]. practice and outcome. Other patient factors such
Reason also describes the human as the hero in as personality, language, and psychological prob-
complex work environments where errors are lems may also be important as they can influence
noticed, corrected, and accidents prevented, far communication with staff. The design of the task,
more frequently than they are missed [8]. the availability and clarity of protocols and
We should emphasise that not every slip, guidelines may influence the care process and
lapse, or mistake needs to be understood in terms affect the quality of care. Individual factors
of the full organisational framework; some errors include the knowledge, skills, and experience of
are confined to the local context and can be each member of staff, which will obviously affect
largely explained by individual factors and the their clinical practice. Each staff member is part
characteristics of the particular task at hand. of a team within the inpatient or community unit,
However, major incidents almost always evolve and part of the wider organisation of the hospital,
over time, involve a number of people and a con- primary care, or mental health service. The way
siderable number of contributory factors; in these an individual practises, and their impact on the
circumstances the organisational model proves patient, is constrained and influenced by other
very illuminating. members of the team and the way they communi-
cate, support and supervise each other. The team
is influenced in turn by management actions and
3.5  ontributory Factors: Seven
C by decisions made at a higher level in the organ-
Levels of Safety isation. These include policies for the use of
locum or agency staff, continuing education,
Reason’s model has been extended and adapted training, and supervision and the availability of
for use in a healthcare setting, classifying the equipment and supplies. The organisation itself is
error producing conditions and organisational affected by the institutional context, including
factors in a single broad framework of factors financial constraints, external regulation, and the
affecting clinical practice (see Table 3.1). broader economic and political climate.
34 H. Higham and C. Vincent

Table 3.1  Framework of contributory factors influenc- We now take the concepts described above
ing clinical practice (from Vincent et al. [9])
and apply them to clinical practice to show how
Factor types Contributory influencing factor chains of errors can combine to cause harm to
Patient factors Condition (complexity and patients. We also examine the role of the wider
seriousness)
Language and communication organisation by considering the various factors
Personality and social factors that contribute to the likelihood of an error and
Task and Task design and clarity of structure harm to a patient. We consider two illustrative
technology Availability and use of protocols cases of common presentations in acute hospital
factors Availability and accuracy of test
settings. The first evolved over several days and
results
Decision-making aids the second over a much shorter time frame
Individual Knowledge and skills (hours). In each case, we see a chain of errors and
(staff) factors Competence other problems in the process of care which com-
Physical and mental health bine to cause harm to the patient. We also, impor-
Team factors Verbal communication
tantly, see how working conditions and wider
Written communication
Supervision and seeking help organisational issues impact on clinical work and
Team leadership how vulnerabilities in the healthcare system pose
Work Staffing levels and skills mix major risks to patients.
environmental Workload and shift patterns
factors Design, availability, and
maintenance of equipment
Administrative and managerial 3.6.1 C
 ase 1: An Avoidable
support Patient Fall
Physical environment
Organisational Financial resources and constraints
Box 3.1 provides an overview of the events lead-
and Organisational structure
management Policy, standards, and goals ing up to an avoidable fall on a medical ward.
factors Safety culture and priorities This 88-year-old man had multiple health
Institutional Economic and regulatory context ­problems and was admitted in a confused and
context factors National health service executive distressed state. He fell while in hospital with
Links with external organisations

3.6  utting It All Together:

P Box 3.1: An Avoidable Patient Fall
Illustration of Two Cases Day 1
from an Acute Care Setting An 88-year-old man was brought to the
emergency department (ED) in the early
Cases and clinical stories have always been used in afternoon by his wife and daughter. He had
medical schools and clinical practice as a means of been becoming increasingly confused at
education and reflection on the nature of disease. home and was not taking care of himself as
The presentation of a case of diabetes, for instance, he normally would. His past medical his-
will illuminate understanding of the evolution of tory included chronic obstructive pulmo-
the disease, potential complications, and impact nary disease, aortic valve replacement for
on the patient and their family. Cases can also be stenosis, a laminectomy for sciatic nerve
used to illustrate the process of clinical decision- decompression, and benign prostatic
making, the weighing of treatment options and hypertrophy. His presenting complaint was
sometimes, particularly when errors are discussed, worsening confusion and hallucinations,
the personal impact of incidents and mishaps. disturbed sleep, poor appetite, and
Incident analysis, for the purposes of improving increased shortness of breath.
the safety of healthcare, may encompass all of He was clerked in by a trainee doctor at
these perspectives but critically also includes 16:20 and seen by a consultant physician at
reflection on the broader healthcare system.
3  Human Error and Patient Safety 35

17:15 when a provisional diagnosis of sep- Day 2

sis of unknown origin was made. A bed The morning ward round was conducted
was found on a medical ward (MW) and by a different trainee doctor and the speech
was transferred from ED at 21:00. and language therapists came to review the
A falls risk assessment was undertaken patient and decided that he was too drowsy
in ED and he was found to be at high risk, and confused to take fluid safely by mouth
unfortunately no falls action plan was made and so the intravenous infusion should con-
and the level of risk was not adequately tinue. The trainee doctor decided that an
handed over to the staff on MW. The family X-Ray of the right hip should be done but
spoke to members of staff in ED and on requested it as a routine investigation and it
MW about their concerns that the patient was not, therefore, prioritised. The hando-
may fall and injure himself particularly as ver to the trainee doctor on call that night
the bed on MW was in a bay at the end of mentioned that the X-Ray had not been
the ward where the patient would not be done and that it needed ‘chasing’.
easy to observe. Day 3
The ward was busy and it was staffed to A different trainee doctor undertook the
agreed levels but the dependency of the ward round and notes concerns were raised
patients was high. The nurse looking after in the nursing notes about bruising around
this patient decided that he was settled and the right knee but the patient also had a low
did not need 1:1 care but asked the care blood pressure requiring closer monitoring
support worker (CSW) to review him regu- and a fluid challenge. By 13:15, the X-ray
larly. The patient was being cared for on a had still not been done and the trainee doctor
bed with side rails (not recommended in called the radiology department. At 16:00,
high risk patients as they can become the trainee doctor was called by the radiolo-
entangled in the rails if they are confused) gist to report a hip fracture and suggest an
and not on a low level bed with “crash mat- urgent referral to the trauma surgeons.
tresses” either side as recommended for While this patient was successfully
patients at risk of falling. treated for his hip fracture and returned
At approximately 21:45 the patient was home, the fall he sustained led to unneces-
found on the floor by the bed having fallen. sary pain, a protracted recovery and added
He was confused and complaining of pain to the concern felt by his family.
in the right hip and thigh. He was reviewed
by the trainee doctor on call whose note
read (sic)
Asked to see patient as unwitnessed fall, long-term consequences for his mobility and
found by nursing staff alert but very con- quality of life. We could easily see his fall as sim-
fused, admitted with confusion and urinary ply being the consequence of his frail condition
tract infection. Plan for ECG, review of and not the fault of healthcare staff. However,
right hip in the morning for development of
swelling/bruising, close observation to pre- whether or not we regard anyone as being at fault,
vent further falls, day team to consider if this story exposes some vulnerabilities in the
further imaging is required. healthcare system.
Following the event outline above, we can
The patient was moved to a bay where identify a series of problems in the care provided
he could be closely observed, the ECG was and a number of wider contributory factors.
reviewed (nothing acute was seen) and the Figure 3.2 provides a summary of the key error
nursing notes recorded an otherwise points during this patient’s admission to hospital
uneventful night with no obvious pain. and includes error types and contributory factors.
36 H. Higham and C. Vincent

The contributory factors in the evolution of this busy with someone else while this patient
incident were a mixture of problems with sys- attempted to get of bed and fell.
tems, organizational, work, and team factors— • The trainee doctor on call on the night of the
the kind of issues seen in most healthcare adverse fall did an appropriate assessment of the
events (these are categorised according to the patient but did not handover his concerns
London Protocol in Table 3.1). about the risk of fracture adequately.
An elderly patient with sepsis is difficult to • On Day 3 the patient had an additional prob-
assess because of their multiple comorbidities and lem (low blood pressure) another different
the difficulties of communicating with someone trainee doctor (without senior assistance)
who is confused. The emergency department and reviewed the patient but was distracted by the
ward were also very busy reducing the time avail- low blood pressure and did not prioritise the
able. Nevertheless, we can identify the following investigation of the hip.
problems or ‘error points’ in the sequence of care:
These are the principle error points (active
• Every adult over 65  years admitted to an failures in Reason’s terms) in the care of this man
acute hospital in the NHS should receive a that played a part in both the fall and to the
falls risk assessment but it was not done delayed diagnosis of fracture. We can also
properly. This patient was assessed for falls (Table 3.2) look at the wide range of factors that
risk and was categorised (appropriately) as contributed to these problems occurring. These
‘high risk’ but no plan to reduce the risk was included: the frailty and confusion of the patient
put in place and the information was not made assessment difficult, the inconsistent meth-
clearly handed over by the ED nurse to the ods for monitoring and recording falls, the inex-
nurse on MW. perience of the junior doctor, the lack of
• Although at high risk of a falls the patient was systematic handover, and the fact that at night the
placed in a bay which was difficult to observe hospital has a lower nurse to patient ratio and that
and not kept under close observation. The other elderly patients required a high level of sup-
Care Support Worker allocated to the bay was port from the nurses on duty.

R-BM DAY 1 Patient admitted to ED with confusion and possible sepsis and
multiple comorbidities - inadequate use of protocol for patients at high
risk of falls, no standard approach to recording falls risk

DAY 1 Patient's family express concerns about risk of falling - handover to

LAPSE
staff on ward inadequate

DAY 1 Admitted to MW at 21:00 five hours after arrival in bed with side
R-BM Key:
rails up - inadequate use of protective measures for patients at high Arrows mark key points in the
risk of falls evolution of the incident
ED - Emergency Department
R-BM DAY 1 Patient has unwitnessed fall - patient in bed at end of busy MW - Medical ward
medical ward, no measures for close observation of patient in place R-BM- Rule-based mistake
K-BM - Knowledge-based
mistake
K-BM DAY 1 Trainee doctor mentions X-Ray but does not order during Contributory factors:
night - failure to detect fracture in confused patient, no senior Patient
Individual
doctor on ward round
Task / technology
DAY 2 Different trainee doctor reviews patient and orders hip X-Ray - Team
K-BM failure to escalate concerns to senior doctor, failure to detect fracture in Work / environmental
confused patient, no senior review Organisational

DAY 3 Different team on ward round, no senior review, patient has

K-BM
low BP, trainee doctor delays chasing hip X-Ray whilst treating BP -
fracture diagnosed 2 days after fall

Fig. 3.2  Error chain describing key error points leading to an avoidable fall and a delay in diagnosis of hip fracture.
Contributory factors (from the London Protocol) are highlighted and colour coded according to type
3  Human Error and Patient Safety 37

Table 3.2  Contributory factors in a case of avoidable fall (from the London Protocol)
Contributory
factors Examples from case of avoidable fall
Patient factors • The patient was elderly and confused making communication and assessment more
challenging (e.g. difficulty communicating pain in the hip after the fall)
• Elderly confused patients find strange environments distressing contributing to the risk of
wandering and falling
• The patient’s comorbidities and acute illness (sepsis, poor swallow, low blood pressure) were
a distraction to staff contributing to the delay in diagnosing the fracture
•  The family raised concerns about the risk of falling but these were not acted on
Task/ • Protocols for the management of patients at risk of falling were not followed, a busy ED, and
technology lack of adequate training in the use of the protocols contributed to this issue
factors • Records of falls risk were made in different ways between clinical settings—the ED used a
computer system and the MW had paper forms
Individual • The trainee doctors did not recognise the risk of fracture after a fall in elderly patients, lack of
factors experience contributed to the delay in prioritising the hip X-ray
Team factors • Missed opportunities in the handover of care within the nursing and medical teams and the
multidisciplinary team overall
• Trainee doctors did not provide adequate handovers regarding the fall and requirement for
investigation to team members taking over care of the patient
•  Trainee doctors did not escalate concerns to a senior member of the medical team
•  No senior medical leadership on ward rounds to support decision-making
Work/ •  Busy medical ward
environment • Complicated, frail patient requiring extensive assistance with activities of daily living on top
factors of the care required for the acute illness
• Providing adequate supervision for a patient at risk of falls is challenging when a ward is
busy and when staff numbers are lower (e.g. at night)
•  The patient was in a bay at the end of the ward making it more difficult to observe him
Organisational • No standardised method of record keeping for falls assessment: electronic records in ED but
factors paper records on MW

3.6.2 C
 ase 2: An Avoidable Box 3.2: An Avoidable Emergency
Emergency Laparotomy Laparotomy in a Case of Ectopic Pregnancy
in a Case of Ectopic Pregnancy A 28-year-old woman with abdominal pain
and lethargy arrived in the busy emergency
Box 3.2 provides an overview of events leading department (ED) at 16:19 and was seen by
up to conversion to emergency laparotomy in a a triage nurse who recorded some baseline
young woman with an ectopic pregnancy. The observations and referred the patient to the
case resonates with the fall described above in the ED trainee doctor, stating that she was “not
sense that it would be easy to see the delayed worried” about the patient. The protocol
diagnosis and treatment as a result of the patient’s for the investigation and management of
youth: her cardiovascular system was able to early pregnancy in ED was inadequate, and
mask the signs of shock and so medical staff did there was a delay in sending the necessary
not suspect haemorrhage. It is only when we take blood samples for diagnosis. The track and
a more holistic view of the incident that we see trigger score was incorrectly calculated and
the latent system and organisational issues which follow-up observations (for heart rate and
are summarised in Fig. 3.3 along with error types. blood pressure) were, therefore, not
Diagnostic challenges are a part of every med- increased in frequency resulting in a delay
ical student’s training and this case illustrates a in calling for an expert opinion from a gyn-
well-recognised situation where haemorrhage is aecologist. The ED trainee doctor did not
masked by the robust response of a healthy car-
38 H. Higham and C. Vincent

recognise the urgency of the situation and staff in theatre. The delays caused by the
when the referral was made to gynaecology equipment problems necessitated a deci-
the handover did not emphasise the seri- sion to convert to an open procedure which
ousness of the situation adequately. The the Consultant made promptly in order to
trainee gynaecologist, therefore, advised gain control of the bleeding. Once the
that the patient be sent to the gynaecology haemorrhage was controlled and additional
ward for further assessment without com- blood products were given the operation to
ing to ED to see the patient. remove the fallopian tube was completed
When the patient arrived on the ward, uneventfully and the patient was stabilised
the senior trainee gynaecologist diagnosed and transferred to recovery with no further
an ectopic pregnancy and recognised that complications.
the patient’s condition was deteriorating This case is similar to the one described
(her haemoglobin had dropped signifi- above in that it contains the same types of
cantly to 99  g/L, her blood pressure was contributory factors and errors that led to
falling, and she was now complaining of the eventual adverse event. The patient
shoulder tip pain). The decision was made recovered well but had to stay in hospital
to take the patient to theatre for emergency longer to recover because the procedure
laparoscopic surgery and because it was was converted to a more invasive surgical
now after 18:00, theatres in the main hospi- approach.
tal were informed and the case was booked
with the on-call anaesthetist. Audits had
revealed that very few gynaecological
emergencies came to theatre after normal diovascular system. However, what is not com-
working hours and consequently gynaeco- monly taught in medical school curricula is the
logical patients were transferred to main risk of missing diagnoses due to distraction and
theatres out of hours. system failures. This young woman’s case illus-
When the consultant surgeon was called trates those problems very well:
(there was a 30 min delay in locating him),
he agreed to come in and assist with the pro- • The nurse in ED was using a poorly designed
cedure. The patient arrived in theatre 5 h protocol for early pregnancy which did not
after the initial presentation with a very low stress the importance of urgent blood
blood pressure and a haemoglobin of samples.
67 g/L. The WHO pre-list briefing was com- • The trainee doctor had limited experience,
pleted without the consultant gynaecologist was busy with other cases, and was influenced
who did not arrive until the patient was by the nurse’s lack of concern. He therefore
anaesthetised and being prepared for surgery did not request an urgent review of the patient.
by the senior trainee gynaecologist and after • Staffing problems in the hospital meant that
the ‘time out’ section of the WHO checklist. emergency gynaecology cases after 18:00 had
At this time, the patient was extremely to be taken to main theatres and transfer time
unwell and there was significantly height- from the gynaecology ward was 20  min.
ened pressure to get on with the procedure. Furthermore, no training was offered to sup-
Tensions were high and when problems port staff in acclimatising to the different work
arose with the laparoscopy equipment (an environment they would be in after hours.
accidentally de-sterilised light source and • The WHO checklist was not used adequately
diathermy forceps which were incompati- which led to a lack of understanding of what
ble with the electrical lead) behaviour dete- type of equipment would be available and no
riorated and exacerbated the stress felt by opportunity for a discussion of potential prob-
lems and their mitigations.
3  Human Error and Patient Safety 39

SLIP Young, fit woman admitted to ED with abdominal pain - urgency not
recognised by ED trainee doctor, nurse calculated track and trigger score
incorrectly

R-BM Delayed transfer to gynaecology ward - inadequate handover,

protocol for managing early pregnancy inadequate

Delayed diagnosis of ectopic pregnancy - senior gynaecology trainee

Key:
working on another site
Arrows mark key points in the
evolution of the incident
Due to delay surgery has to be done in main theatres - all emergency ED - Emergency Department
R·BM- Rule-based mistake
gynae surgery after hours takes place in main theatres
K-BM - Knowledge-based
mistake
Contributory factors:
Variance in equipment not picked up - whole team not present for Patient
R-BM
WHO briefing Individual
Task / technology
Team
Problems with equipment for surgery - staff in main theatres unfamiliar Work / environmental
SLIP with laparoscopic equipment, consultant surgeon unfamiliar with main Organisational
theatres, failure to speak up about concerns re unfamiliarity

Patient's condition deteriorates conversion to open procedure required -

K-BM high stress levels in a team which does not normally work together,
consultant gynaecologist unaware of instrument problems

Fig. 3.3  Error chain describing key error points in a case of emergency laparotomy for ectopic pregnancy. Contributory
factors (from the London Protocol) are highlighted and colour coded according to type

• The gynaecologists were not used to the scrub comparison with methods available in industry
staff or the theatre environment and equip- [10]. In the USA, the most familiar is the root
ment and when the situation became stressful cause analysis approach of the Joint Commission,
the team did not function effectively and had an intensive process with its origins in Total
to perform a more invasive operation to con- Quality Management approaches to healthcare
trol the bleeding. improvement [11]. The Veterans Hospital
Administration has developed a highly structured
These are the principle error points leading to system of triage questions which is being dis-
the emergency conversion to laparotomy in what seminated throughout their system. We do not
could have been a more straightforward laparo- have space to examine all potential methods,
scopic procedure. The heightened stress in this which vary in their orientation, theoretical basis,
situation further impaired team function but the and basic approach. All however, to a greater or
‘upstream’ delays in diagnosis, staff shortages, lesser extent, uncover factors contributing to the
and the physical location of the ward and theatres final incident. We will summarise an approach
along with organisation of the gynaecology ser- developed at University College London by the
vice out of hours all contributed to the ultimate Clinical Safety Research Unit known, imagina-
crisis (see Table 3.3 for detailed categorisation of tively, as the London Protocol [12].
contributory factors). Most other approaches to analysing incidents
in healthcare are termed ‘root cause analysis’; in
contrast, we have described our own approach to
3.7 Conducting Your Own the analysis of incidents as a systems analysis as
Incident Investigation we believe that it is a more accurate and more
fruitful description. The term root cause analysis,
There are a number of methods of investigation while widespread, is misleading in a number of
and analysis available in healthcare, though these respects [13, 14]. Most importantly, it implies
tend to be comparatively under-developed in that the purpose of an investigation is to identify
40 H. Higham and C. Vincent

Table 3.3  Contributory factors to a gynaecological emergency

Contributory
factors Examples from case of ectopic pregnancy
Patient factors • The patient’s initial presentation was not overtly serious (she was young and so signs of shock
were masked) and led to a false sense of security in a less experienced member of the team
(the ED trainee doctor)
• The patient’s rapid deterioration in theatre led to heightened stress amongst the staff in theatre
and impaired performance
Task/ •  The protocol for the management of early pregnancy in ED was not adequate
technology • The WHO briefing should have provided an opportunity to highlight the concerns about
factors equipment but not all team members were present
Individual •  The trainee doctor in ED lacked experience in the management of early pregnancy
factors • The scrub staff in theatre knew where the gynaecology equipment was kept but were not
using it regularly and did not have regular training to maintain their competencies. When
under pressure, the challenge of using unfamiliar equipment was too much
•  The two gynaecologists were working in an unfamiliar theatre environment
• During the most stressful time, the consultant gynaecologist became angry which caused
additional stress to the other staff and led to impaired performance
Team factors •  This team did not work together regularly
•  The WHO briefing was not done with the whole team present
• There was no regular programme of simulated emergency training to support the development
of teamworking skills in a crisis
Work/ •  There was a shortage of theatre staff in gynaecology
environment • The gynaecology ward and theatres are on another part of the hospital site, distant from ED
factors and main theatres
• It was not possible to staff gynaecology theatres out of hours. This necessitated transfer of
gynaecology emergencies to main theatres (which took 20 min)
• The theatre environment and equipment in the main suite was very different from
gynaecology theatres
Organisational •  Recruitment and retention of theatre staff was a problem across all theatre sites
factors •  Theatre suites had been designed and built at different times with no standardisation

a single or small number of ‘root causes’. If you Table 3.4  Critical incident paradigms (adapted from
look back at the two case examples however you Woods et al. [15])
will see that there is no ‘root cause’. Our analyses Old view New view
have shown a much more fluid and complex pic- Human error is seen Human error is seen as the
ture. Usually, there is a chain of events and a wide as a cause of failure effect of systemic
vulnerabilities deeper inside
variety of contributory factors leading up to the the organisation
eventual incident. Incident analysis, properly Saying what people Saying what people should
understood, is not a retrospective search for root should have done is a have done does not explain
causes but an attempt to use the incident as a satisfying way to why it made sense for them to
describe failure do what they did
‘window on the system’ to reveal the vulnerabili-
Telling people to be Only by constantly seeking
ties and hazards that are constant threats to more careful will out vulnerabilities can
patient care. make the problem go organisations enhance safety
Too often the questions asked about an inci- away
dent focus on “who?” rather than “how?” with
the result that individuals rather than systems just culture where learning from incidents
are targeted and blamed. High reliability organ- (including near misses) is encouraged and
isations have recognised the need to move away expected. The paradigm shift in these organisa-
from a culture of blame, which leads to reluc- tions is outlined in Table 3.4 but, unfortunately,
tance to report incidents, and have developed a is not yet well developed in healthcare [15].
3  Human Error and Patient Safety 41

3.8  ystems Analysis of Clinical

S viewer can reflect together on the contributory
Incidents factors, which greatly enriches both the interview
and investigation.
During an investigation, information is gleaned Analyses using this method have been con-
from a variety of sources. Case records, state- ducted in hospitals, primary care settings, and
ments, and any other relevant documentation are mental health units. The protocol may be used in
reviewed. Structured interviews with key mem- a variety of formats, by individual clinicians,
bers of staff are then undertaken to establish the researchers, risk managers, and by clinical teams.
chronology of events, the main care delivery A clinical team may use the method to guide and
problems and their respective contributory fac- structure reflection on an incident, to ensure that
tors, as perceived by each member of staff. the analysis is full and comprehensive. For seri-
Ideally, the patient, or a member of their family, ous incidents, a team of individuals with different
should also be interviewed though as yet this is skills and backgrounds would be assembled
not yet common practice in these analyses. The though often only a risk manager or an individual
key questions are ‘What happened? (the outcome clinician will be needed. The contributory factors
and chronology); How did it happen? (the errors that reflect more general problems in a unit are
and care delivery problems); and Why did it hap- the targets for change and systems improvement.
pen? (the contributory factors)’. When obvious problems are identified action
Once the chronology of events is clear there may be taken after a single incident, but when
are three main considerations: the errors and more substantial changes are being considered
other care delivery problems identified within the other incident analyses and sources of data (rou-
chronology, the clinical context for each of them, tine audits and outcome data) should also be
and the factors contributing to the occurrence of taken into account.
the care delivery problems. Any combination of
contributory factors might contribute to the
occurrence of a single care delivery problem. The 3.8.1 F
 rom Analysis to Meaningful
investigator needs to differentiate between those Action
contributory factors that are only relevant on that
particular occasion and those which are long- When considering the error type in the context of
standing or permanent features of the unit. For the contributory factors at the time of the error, it
instance, there may be a failure of communica- becomes clearer how meaningful interventions
tion between two midwives which might be an might be made to prevent similar incidents in
isolated occurrence or might reflect a more gen- future. Sometimes incident investigations point
eral pattern of poor communication on the unit. to immediate changes that need to be made, such
While a considerable amount of information as replacement of faulty equipment or updating
can be gleaned from written records, interviews of misleading or inconsistent guidelines.
with those involved are the most important Generally, however, we should not generate plans
method of identifying the contributory factors. for major interventions on the basis of a single
This is especially so if the interview systemati- incident but draw on a wider range of informa-
cally explores these factors and so allows the tion and check that the findings of the incident
member of staff to collaborate in the investiga- are really indicative of more widespread prob-
tion. In the interview, the story and ‘the facts’ are lems. We can nevertheless think about usual
just the first stage. The staff member is also intervention that might be made on the basis of
encouraged to identify both the successful aspects our analyses of the two cases.
of the care provided and the errors and care deliv- For example, in the first case there were sev-
ery problems. Both staff members and inter- eral rules-based mistakes. The protocol for falls
42 H. Higham and C. Vincent

assessment and prevention was not used ade- line rather than a change to the procedure requir-
quately by the nurses. Some important contribu- ing additional checks to be made). However, in
tory factors were the inconsistencies in falls risk a financially constrained health service some-
assessment and recording and also the staffing times physical interventions may be prohibitively
shortages at critical times. These suggest poten- expensive and well-designed checklists with
tial interventions: training to support embedding them in practice
may be the best compromise [16].
• A review of staffing levels and consideration
of different working patterns to cover busy
times more effectively could help 3.9 Supporting Patients,
• Standardising the way falls risk assessments Families, and Staff
are recorded across all clinical areas (the
use of electronic patient records can help In this chapter, we have focussed on understand-
here) ing how error and harm occur and offered mod-
els of understanding and practical approaches to
The second analysis reveals a rather different investigation. We have hopefully persuaded you
range of problems and contributory factors and, that understanding the wider psychological and
correspondingly, different types of potential organisational influences on clinical practice
interventions. Undertaking an emergency lapa- will enrich your approach to medicine and pro-
roscopy is not an unusual occurrence in gynaeco- vide a foundation for improving the care pro-
logy but the knowledge-based mistake leading to vided to patients. The chapter would be
conversion to an open procedure can be better incomplete however if we did not mention, if
understood when we realise that staff were unfa- only briefly, the need to also consider the after-
miliar with each other and their equipment and math of serious errors and the needs of those
environment, the WHO checklist was done in a affected [17].
hurry and without the consultant surgeon present The impact of a medical injury differs from
and that staff had not previously trained as a team most other accidents in two important respects.
to deal with crisis situations. Potential interven- First, patients have been harmed, unintention-
tions, therefore, might be: ally, by people in whom they placed consider-
able trust, so their reaction may be especially
• Scrub staff from gynaecology theatres could powerful and hard to cope with. Secondly, and
work on a rotational basis in the main theatres even more important, they are often cared for by
to ensure they used the environment and the same professions, and perhaps the same peo-
equipment and equipment could be stan- ple, as those involved in the original injury.
dardised across sites They may have been very frightened by what
• Training to embed good practice in the use of has happened to them, and have a range of con-
the WHO checklist for theatre teams flicting feelings about those involved; this too
• Regular simulation training to support staff in can be very difficult, even when staff are sympa-
the management of emergencies thetic and supportive. Many people harmed by
their treatment suffer further trauma through the
The design and implementation of realistic incident being insensitively and inadequately
and sustainable interventions to prevent inci- handled. Conversely when staff come forward,
dents recurring is a topic outside the scope of this acknowledge the damage, and take the neces-
chapter. Suffice it to say that where possible the sary action, the overall impact can be greatly
implementation of a physical rather than a pro- reduced.
cedural intervention is more likely to succeed In our two examples, the patients eventually
(e.g. the design of a device to prevent retention of recovered although both experienced much
guidewires after the insertion of a central venous unnecessary anxiety and suffering in the process.
3  Human Error and Patient Safety 43

However, the long-term consequences some seri- and for the sake of all the patients they will be
ous incidents can be life changing in terms of looking after in the future.
pain, disability, and effect on family relationships High reliability organisations have spent
and the ability to work. Patients and families decades developing robust, standardised systems
need support immediately after the serious inci- of investigating incidents including the establish-
dent and sometimes over long periods afterwards. ment of truly independent expert investigative
The healthcare organisation concerned has a bodies (such as the UK’s Air Accident
responsibility to provide or arrange for this care. Investigation Branch, https://www.gov.uk/gov-
Injured patients need an explanation, an apology, ernment/organisations/air-accidents-investiga-
to know that changes have been made to prevent tion-branch). Healthcare has learnt from some of
future incidents, and often also need practical and these lessons and in April 2017 the Healthcare
financial help. The absence of any of these fac- Safety Investigation Branch was established in
tors can be a powerful stimulus to complaint or the NHS (https://www.hsib.org.uk) with the
litigation. stated purpose of ‘improving patient safety
Staff also suffer a variety of consequences through effective and independent investigations
when involved in serious incidents. Albert Wu that don’t apportion blame or liability’. Their
captured the experience of making a serious error work has only just begun but will draw on exist-
in his paper ‘the second victim’, not implying ing expertise in the NHS to capture the widely
that the experiences of staff were necessarily shared ambition of learning from the past to
comparable to those of injured patients [18]. improve the future.
Surgeons, for instance, can be seriously affected Some branches of medicine, most notably
by serious complications that they perceive to anaesthesia, have been at the forefront of devel-
have been their fault. Emotional reactions range opments in patient safety [20, 21]. Human fac-
from guilt and crisis of confidence, to anger and tors is a core theme throughout the postgraduate
worry about one’s career. Even though the intense curricula for anaesthesia training and quick ref-
emotional impact progressively fades, there are erence handbooks (much like those in the mili-
certain cases that surgeons recollect many years tary or civil aviation) have been developed as
later. Serious complications often make surgeons cognitive aids for diagnostic challenges particu-
more conservative or risk-adverse in the manage- larly in crises (https://anaesthetists.org/Home/
ment of patients, which can be detrimental for Resources-publications/Safety-alerts/
patient care [19]. Anaesthesia-emergencies/Quick-Reference-
Handbook). These developments in postgraduate
specialty curricula must be extended to under-
3.10 Conclusions graduate teaching in medical and nursing
and Recommendations schools. It is only by ensuring that young profes-
sionals in healthcare are equipped with the nec-
It is an unfortunate truth that the prevailing cul- essary tools to understand the complex, rapidly
ture around serious incidents in healthcare evolving systems in which they will be working,
remains one of blame. When a serious incident that they will be able to improve them [22].
occurs, the first priority is obviously the care of
the patient and family. The second priority how-
ever should be supporting colleagues and not References
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2. Hollnagel E.  Cognitive reliability and error analysis
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cause, prediction, and reduction. Hillsdale, NJ: Sarter N.  Behind human error. Farnham: Ashgate;
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incidents and adverse events in healthcare. Health ulation to enhance training and patient safety in anaes-
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 Looking to the Future
4
Peter Lachman

Learning Objectives “clinical diagnosis” subject to tests and interven-

• Understand the future challenges for patient tions. As a result, the needs of the person were
safety changed, and their narrative was not as important
• Describe how psychological safety is essential as the medical tests and investigations. There
for safety have been many benefits in the development of
• List the social determinants of patient safety modern medicine and the science that was cre-
• Comprehend the concepts of co-production of ated to provide successful interventions. People
safety who became patients were cured or provided lon-
• List facilitators and risks of new technologies gevity. This in turn has resulted in the new chal-
for safety lenges of chronic disease and the ageing
population [2]. Unfortunately, in many societies,
there are both the old problems of infection and
4.1 Introduction late treatment of disease, as well as the new prob-
lems of ageing and chronicity. In addition, eco-
In this chapter, I will explore the issues that we nomic and political decisions have created a vast
need to address as we proceed on the safety jour- challenge of poverty-related healthcare with
ney. This will include reflections on the beliefs poorer outcomes.
that have resulted in the healthcare system we Alongside the technological advance, we also
have created. It is important to consider the real have the loss of the compassionate part of healing
issues of design and whether we need to change which has had a major impact on the psychologi-
all aspects of healthcare delivery if we really cal safety of healthcare providers and the people
want to be safe. who receive care. The improvement in outcomes
It is clear that the rapid progress in medical in terms of disease management has been accom-
science over the past century has resulted in panied by increasing levels of adverse events and
untold benefits for all. Foucault [1] described the harm. The development of the patient safety
emergence as the development of the “clinical movement over the past 20 years is a reflection of
gaze”, whereby the person became a patient with the advances in healthcare and the realisation that
a disease, so was no longer a person, but rather a with success came a new problem of inadvertent
harm. On reflection, healthcare delivery was not
P. Lachman (*) planned to be safe.
International Society for Quality in Health Care As we look to the future, the healthcare indus-
(ISQua), Dublin, Ireland try is at a critical juncture. The rapid develop-

© The Author(s) 2021 45

L. Donaldson et al. (eds.), Textbook of Patient Safety and Clinical Risk Management,
https://doi.org/10.1007/978-3-030-59403-9_4
46 P. Lachman

ment of theories on how to deliver safe, all the domains of quality. To achieve a safe sys-
person-centred care means that we can no longer tem, we will need to address some fundamental
rely on the excuse that “healthcare is different” issues that we have accepted as the norm.
from other industries, so cannot be reliable and
safe. People are now demanding safety and reli-
ability in the care they receive, and they want to 4.2 The Vision for the Future
be treated as people who happen to be ill, rather
than as a number or a disease. Currently, it is by The future vision is often reflected in the concept
chance rather than by design that one receives of Zero Harm. There are movements to apply the
highly reliable person-centred and safe care. Yet standards to medicine that we accept in other
we continue to build the same type of hospitals, industries. The argument for and against zero harm
educate future nurses and clinicians as we have is compelling. If we do not aim for zero, what is
always done, and operate in a hierarchical system the number we need to aim for? It may be that we
that disempowers people, rather than enables aim for zero in some specific areas while accepting
people to be healthy. that within the complexity of the healthcare zero,
An examination of the patient safety move- the totality of zero is a mirage, one that we need to
ment provides an understanding of where we aim for but will never reach. It has been argued
need to go as we plan for the future. With some that the ideal of Zero Harm is unrealistic [7], that
imagination, we can redesign the processes of we should accept the inherent risk in the delivery
care to be compassionate and safe. Bates and of healthcare and therefore actively adopt patient
Singh [3] note that there has been much progress safety initiatives to improve outcomes and mini-
since the publication of To Err is Human [4]. We mise risk. Furthermore, we need to accept the
have learnt many methods of quality improve- stresses healthcare systems face in the delivery of
ment, and patient safety as a science has numer- care—be it of demand, finance, or morale.
ous theories, methodologies, and tools that, if
implemented, can decrease harm: “Highly effec-
tive interventions have since been developed and 4.3  he Challenges to Overcome
T
adopted for hospital-acquired infections and to Facilitate Safety
medication safety, although the impact of these
interventions varies because of their inconsistent The pursuit of a healthcare system that is safe
implementation and practice. Progress in will require courage, as the current power base is
addressing other hospital-acquired adverse not conducive to safe care. The power of the
events has been variable” [3]. medical profession, pharmaceutical industry, and
Amalberti and Vincent [5] have taken the view supporting bodies is based on the current model
that the healthcare delivery system has inherent of care, with hierarchies and structures. Hospitals,
risk and that the focus of patient safety should be as a concept, gained their power in the last cen-
on the proactive management of that risk. This is tury and were developed for the illnesses that we
true of any complex adaptive system, which have now addressed, so the next stage is to inte-
makes it difficult to be safe all the time [6]. grate that power with the wider health commu-
However, the health system has not been designed nity. This will result in changing the power
with safety as the core function. Given that we imbalance in the system and the recognition that
know that there is more complexity, perhaps a the design of a system with the hospital at the
total redesign of the system is the way we need to centre can be changed to the hospital as the facili-
go as we move to the future. tator of health within a system of care delivery
Although the provision of healthcare is com- which is focused closer to the home. This will
plex, it is possible to overcome the complexity require a reallocation of resources to primary
and provide care that is of the highest standard in care and a change of healthcare to health. There
4  Looking to the Future 47

is a way forward to address these key issues and 4.4 Develop the Language
there is hope that in time healthcare delivery and and Culture of Safety
the promotion of health will be safe with proac-
tive minimisation of risk. People will still be • Use of the language that enhances safety
harmed; however, the degree of harm will be dif- • Leaders asking the right questions about
ferent to the current situation. As we redesign safety
services to be safer in the future, we will need a • Educate people for safety
vision that sees beyond the current challenge and
plans for an integrated service of care focused on As healthcare is a complex system, so is the
health rather than disease (Box 4.1). culture which is manifest within any organisa-
tion. Culture defines our belief systems and in
turn how we behave. Within any organisation this
will be complex, with differing safety cultures
Box 4.1: Changes for the Future [8]. The culture we represent is evident in the lan-
1. Develop the language and culture of guage we use. Patient safety is the current termi-
safety nology and as we move to a more people-centred
• Use the right language about safety approach, the language we use will evolve to
• Leaders ask the right questions about being people centred rather than patient focused.
safety Language reflects culture, so if we want to
• Educate people for safety develop a safety culture, then we will need to
2. Promote psychological safety critically analyse the terminology we use.
• Care for both physical and psycho- Healthcare is a misnomer as it focuses on disease
logical safety of people management, whereas we need to focus on health
• Nurture providers of care and pro- and the maintenance of both physical and mental
vide meaning in work well-being. Patients will be protected if we view
• Ensure that providers of care have a them as people with a disease, with a life outside
sense of belonging the disease, rather than as patients with a disease.
• Listen to and hear person stories This results in a loss of power and control over
3. Design for safety their own lives and lack of power may be a con-
• Invest in health rather than tributing cause of harm.
healthcare Patient Safety is the overall science, Risk
• Co-produce safety with people not Management was the first intervention that was
with patients developed in the safety journey. In essence, this
• Place people in charge of their health, was not about managing risk but rather about man-
not their disease aging incidents that had occurred. While this is
• Use human factors to address essential, it has not resulted in a decrease in harm
complexity and the learning from it has not been as great as it
4. Social determinants for Patient Safety should be. The move to learning from investiga-
• Recognise the importance of social tion has been one of the greatest challenges we
determinants of health and their have faced. If one considers the integration of
impact on safety resilience engineering into the risk management
• Care is culturally sensitive and pro- approach, then the incident investigation will be a
motes safety study of work as it really is over the pathway and
5. Harnessing technology for the future not the incident. We now need to move to the con-
• Digital health for safety cept of looking at the patient journey and how
• Empowering people with health is provided, so that the person is protected
technology at all parts of the journey [9]. Management of risk
is a proactive activity and is what should happen at
48 P. Lachman

all times, not only when there is an incident. It need to be open and transparent with patients and
implies the acceptance of risk rather than the their families.
desire to eliminate risk, and constant mitigation The healthcare workforce will require an edu-
will decrease the potential for harm. cation that enables them to deliver health as well
Another example of language ambiguity is the as manage disease safely. This will require an
term, “near misses”, which is used for when we understanding of the theories of Complexity
nearly harm a person but then either due to the Science, Systems Theory, Patient Safety Science,
action of an individual, or by chance the person is and Human Factors. Medical curricula must be
not harmed. This is really a near hit and if it were challenged and changed to educate the clinicians
termed as such, perhaps we would pay more that we require in the future [10].
attention to the problem.
Leadership for safety will be the foundation of
future work in patient safety. Leaders in health- 4.5 Promote Psychological
care are at all levels in the system, as there needs Safety
to be a focus in every microsystem as well in the
de facto leadership at executive level. This • Care for both physical and psychological
includes the appreciation of uncertainty, the inte- safety of people
gration of information from different sources and • Nurture providers of care and provide mean-
the setting of the goals that will allow for the ing in work
development of safe systems. Leadership, there- • Ensure that providers of care have a sense of
fore, needs to be encouraged at all levels of the belonging
organisation, with the development and facilita- • Address the challenge of clinician burnout
tion of local leadership at the interface with the
patient as the key to ensure that there will be a Psychological safety is the foundation for pro-
safe environment. Change will require leaders viding safe care for individuals. The work by
who understand what quality, safe person-centred Edmondson has led the way to understanding
care really is, with a deep understanding of that, in order to deliver safe care, we need to
Systems Theory and Human Factors, as well as engender the “psychological safety” of individu-
knowing how to realign the budget to facilitate als in the health workplace, so that they in turn are
change. This requires vision to set the direction, part of the overall culture of safety. Edmondson
hope to provide succour in trying times, respect defines psychological safety as a “shared belief
for what is being changed and for the work that is held by members of a team that the team is safe
done, and courage to make the changes against for interpersonal risk-taking” [11–13].
the resistance that the past ways will present. The safety movement has called for organisa-
At a policy level, the wider implication of a tions to facilitate safety culture, in which indi-
total redesign of the system will require political viduals have responsibilities to be safe and to
will to allow the realignment and re-engineering carry out their work in a manner that will miti-
of the healthcare system to one in which all pol- gate against harm. Given the complexity of the
icy is aimed at the long-term health of the com- type of work undertaken in healthcare, this is dif-
munity. Politicians need to invest in health while ficult to achieve within the current hierarchical
funding healthcare. constructs of most health organisations.
All of this change will require courage and While some hierarchy is essential, the ability
imagination, vision, and hope. But more impor- to take risks and feel able to challenge in order to
tantly, it will require co-production with all the promote safe practices is one of the major chal-
people involved, particularly people who will be lenges we will face going forward. Investigations
receiving care. The patient safety movement has of clinical incidents usually identify communica-
tended to apply tools and methods to people, tion issues in which hierarchy prevents the com-
rather than designing with them. This implies the munication of potential risk, teamwork being
4  Looking to the Future 49

problematic and blame being present. The con- The patient safety movement has been focused
cept of psychological safety is now central to the on healthcare which really implies that it is con-
development of safe systems, and is therefore as cerned with the negative impacts in the manage-
important as the development of tools and meth- ment of disease. The future of the movement will
ods to facilitate safe care. Much of the concepts transcend disease and focus on maintaining the
of building resilience in healthcare organisations health of people, even when they have disease.
will require attention to how we support all mem- This approach implies that people with a disease
bers of staff to be part of teams with a sense of need to have their physical and mental health
belonging in which the meaning of work includes beyond their disease protected at all times by
safety of the individuals, supported to challenge minimising the risk of harm. To achieve this aim,
and able to learn in real time. we need to move to a new paradigm, and change
The concepts of safety need to build the resil- the current design of our healthcare system,
ience by also learning from what works within the which is focused on physiological systems rather
complexity of care delivery to address the well- than the person as a whole. This implies a change
being of clinicians [14]. Included in the develop- in the systems we have created, which have been
ment of a safe environment will be an active medically focused. It does not imply that we
programme to prevent burnout of clinical staff as destroy all we have, but rather that we examine
this has a negative impact on both their well-being people flows, human factors, and safety from the
and the safety of patients. Prevention of burnout eyes of the person receiving care.
has not been part of the traditional patient safety The concept of engaging with the people who
interventions, yet stressed clinicians are unable to receive care has become central to the person-­
deliver safe care. Interventions. As we take a sys- centred care movement. The person-centred care
tems and human factors approach to patient safety, approach is more than asking about satisfaction
part of that approach will be the management of and experience, but rather in sharing responsibil-
burnout taking into account the multifactorial rea- ity for health and becoming partners in health-
sons from education, hierarchies, technology, and care provision. The realisation that we cannot be
overall design of the service [15]. safe without the involvement of the people who
The progress made in development of inter- we care for in the planning and design of services
ventions will now be matched by the concept that has led to the concept of co-production, in which
the delivery of healthcare requires the concept of people are part of the solution rather than part of
patient safety is our core business and all that we the problem [16–18]. This approach implies a
do need to be focused on safety. Therefore, all radical rethink on how we define adverse events,
people working in the healthcare setting need to how we look at harm from the viewpoint of the
be supported to be safe and to proactively work to family and person harmed, and how we investi-
their own safety from a psychological and physi- gate safety incidents with the inclusion of the
cal perspective. The safety of the people for who patient as a person, not as a patient. It will require
they care will then follow. a re-evaluation of clinical risk, a change in the
power imbalance and real consultation with peo-
ple about risk and the relative benefit of interven-
4.6 Design for Health tion. Co-production also implies that we co
and for Safety design safety not only with the people we call
patients, but also with the providers of care who
• Invest in health rather than healthcare have to be safe all the time, despite the inherent
• Co-produce safety with people not with risk of the clinical processes and especially in
patients trying conditions.
• Place people in charge of their health, not their To achieve safety within clinical process will
disease require the integration of safety design as part of
• Use human factors and ergonomics to address the day-to-day operations. Human Factors and
complexity Ergonomics (HFE) has been a marginal topic in
50 P. Lachman

healthcare, pursued by enthusiasts rather than the development of interventions that empower
being core to the programmes that we run. In people and address the impact poverty and disad-
other chapters, the HFE theories have been pre- vantage have on safety.
sented. HFE will be as integral to medical educa- From a global perspective, the work by the
tion as anatomy and physiology, so that it is a Lancet Commission on the increased risk to the
seam that runs through all of our thinking [19]. people in the poorer nations of the Lower and
Middle Income Countries indicates that we will
need more than the patient safety methodologies
4.7 Social Determinants to protect people in those countries from harm
of Patient Safety [23]. In the future, the Social Determinants of
Patient Safety (or SDPS) will be as important in
• Define the importance of social determinants understanding how to prevent harm as are the
of patient safety methods and interventions we use to mitigate
• Design care that is culturally sensitive and against adverse events.
promotes safety

In recent years, the importance of the determi- 4.8 Harnessing Technology

nants of health outcomes has been highlighted for the Future (Reference
with the studies that indicate that people who are Chap. 33)
less well-off economically, are from ethnic
minorities or marginalised groups have worse • Digital health for safety
health outcomes. Poverty, housing, education, lit- • Empowering people using technology
eracy, and nutrition are a few of the factors that • Understand the opportunities and risks of
interplay to cause clinical presentations, as well Artificial Intelligence
as the outcome of treatment be it due to poor
access, lack of health literacy, or institutionalised The challenge we face in the patient safety
prejudice [20]. Health outcomes can be predicted movement is how we harness the great potential
depending on the influences of the social deter- of the digitalisation of health and the introduction
minants. The poorer one is, the worse is the clini- of Artificial Intelligence to healthcare delivery.
cal outcome. Poverty influences life expectancy, The potential to use new technologies to design
the type of diseases to which one will succumb, out human medical error and resultant harm is
the access to health, and the quality of healthcare great. Nonetheless, it is not necessarily the solu-
[21]. The patient safety movement has not tradi- tion to the challenge of patient safety, but rather
tionally researched the impact of the social deter- an aid towards safer care [24, 25]. The potential
minants of health on the risk of harm, either for of Electronic Health Records, electronic pre-
individuals or for communities [22]. scribing, and computer ordering systems to
It is logical to expect that people who are poor, address the communication and transcription
have low health literacy, and do not have equal challenges in patent safety are still to be realised.
access to the healthcare system, are likely to be at They have not overcome communication issues,
risk of harm due to the immense power differen- but offer us the opportunity to have better com-
tials and the institutionalised prejudice they expe- munication and easier pathways, if the imple-
rience. If one adds ethnicity, gender, language mentation is successful. The challenge is to not
and status, e.g. refugee or homeless, then the out- replace old errors with new ones [26]. As most of
come is likely to be even worse. The challenge the implementation has been in upper income
for the patient safety movement is to acknowl- countries, the spread of digital solutions around
edge the inequity and to mitigate against it in the the globe will need to be carefully considered to
design of programmes. We need to measure this ensure that the lessons learnt are applied with the
perspective of patient safety in order to allow for safety of patients at the core.
4  Looking to the Future 51

For people receiving care, the use of smart References

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 Safer Care: Shaping the Future
5
Liam Donaldson

5.1 Introduction Research and Quality (AHRQ) [5], the European

Commission [6], and the Organisation for
Understanding of, and commitment to, patient Economic Development (OECD) [7] have pro-
safety worldwide has grown since the late 1990s. duced strategic documents, conducted studies,
This was prompted by two influential reports: To provided evidence and guidelines, initiated pro-
Err is Human [1] produced by the Institute of grammes of action, and galvanised the support of
Medicine (now called the National Academy of political and health leaders worldwide.
Medicine) in the USA and An Organisation with This has led to a remarkable transformation in
a Memory [2] produced by the United Kingdom the way that patient safety is viewed. Having
Government’s Chief Medical Adviser. Both been a subject of minority academic interest, it is
reports recognised that error was routine during now a firm priority for most healthcare systems.
the delivery of healthcare: affecting something Yet, the current state of patient safety world-
like one in ten of all hospital patients. In a pro- wide is still a source of deep concern. As data on
portion of cases, the outcome produced was seri- the scale and nature of errors and adverse events
ous, even fatal. have been more widely gathered, it has become
The reports also drew attention to the poor apparent that unsafe actions are a feature of virtu-
performance of healthcare, as a sector, world- ally every aspect of healthcare. Furthermore,
wide on safety compared to most other high-risk there is paucity of research on the frequency of
industries. Notably, aviation has shown remark- errors and their associated burden of harm in
able and sustained improvements in the risk to areas such as primary care and mental health.
passengers of air travel over four decades. Both Reports of the apparently avoidable deaths of
reports called for greater focus on, and commit- patients regularly feature in media reports in
ment to, reducing the risks of healthcare. many countries and undermine public confidence
Since then, the quest to improve the safety of in the health services available to citizens.
care for patients has become a global movement. Moreover, many events recur with efforts to pre-
Important bodies like the World Health vent them, on a large scale, proving ineffective.
Organization (WHO) [3], the Gulf Cooperation Expert commentators have explained this, in part,
Council (GCC) [4], the Agency for Healthcare as being due to a punitive culture of individual
blame and retribution holding back an approach
L. Donaldson (*) that emphasises learning, not judgement as the
London School of Hygiene and Tropical Medicine, route to improvement.
London, UK
e-mail: [email protected]

© The Author(s) 2021 53

L. Donaldson et al. (eds.), Textbook of Patient Safety and Clinical Risk Management,
https://doi.org/10.1007/978-3-030-59403-9_5
54 L. Donaldson

In this chapter, I will reflect on some of per- Rather there is a complex interaction between a
spectives in patient safety that the world of varied set of elements, including human behav-
healthcare has adopted. These, and others, are iour, technological aspects of the system, socio-­
dealt with in-depth in later chapters. I will also cultural factors, and a range of organisational and
set out some of the key developments in the procedural weaknesses [10, 11].
global level journey on patient safety. Wide scale systematic studies of these issues
in healthcare are less common than in other high-­
risk industries, but available evidence suggests a
5.2  hinking About Safer
T similarly complex pattern of cause and effect
Healthcare relationship [12, 13].
Understanding the underlying reasons, or root
By the end of the twentieth century, there was causes, of why things go wrong is critical for suc-
growing interest in avoidable adverse outcomes cess. The deeper causes of adverse patient inci-
of healthcare from some clinical groups, research- dents do, indeed, lie in the management and
ers, and campaigners as well as victims of organisational systems that support the delivery
healthcare-­induced harm and their families. The of care. Research has shown that the causes are
term used most widely at that time to describe rooted in factors such as inadequate training, lack
such events was “medical error” [8]. It still is of communication, lack of information, faulty
quite a common descriptor but the domain of equipment, or poor physical environment. Asking
healthcare that deals with risk of harm to patients staff to work in these conditions will risk causing
and its prevention is now almost universally harm to patients.
called “patient safety” [9]. Building safety into health services by under-
In any complex system like a health service, standing the sources of risk within systems and
human error, and mistakes—and hence adverse eliminating them must be a core priority for all
events—are inevitable. A programme to improve providers of healthcare (Table 5.1).
safety for patients cannot be based on eliminating The key principle in safety generally (not just
error and mistakes—that would be impossible. A in healthcare), that unsafe systems provoke
healthcare system, though, can reduce the occur- human error, is a different way of looking at the
rence of human error, minimise its impact on the world, and requires a different philosophy of
patient when it does occur and learn so that practice.
actions can be taken to protect future patients. It was the introduction of experts from other
fields that changed the way that healthcare looked
at its own accidents and errors. No longer would
5.2.1 Accidents and Incidents:
The Importance of Systems Table 5.1  Ten practical questions to ask about risk in a
clinical service
In exploring the reasons why things go badly 1 Describe the risks: what could go wrong?
wrong in healthcare, it becomes clear that its situ- 2 What is being done to manage the potential risks?
ation is not unique. There are many parallels with 3 What are the consequences if risks not managed?
other sectors. Research and best practice experi- 4 Are the sources of the risks clinical,
ence outside the healthcare field has shown that organisational, or both?
5 How often will the risks occur?
safety comes down to appreciating that big
6 Can you rate the risks’ severity?
improvements are not made by telling people to
7 What level of control is there over the occurrence
take care but by understanding the conditions that of the risks?
provoke error. 8 What action is necessary to reduce the risks?
Extensive study in the non-health field has 9 How will the reduction in risks be sustained?
shown that with most unintended failures there is 10 How will you make all relevant staff aware of the
usually no single explanatory cause for the event. risks?
5  Safer Care: Shaping the Future 55

Other holes due to

latent conditions
HAZARDS
Some holes due to
active failures

S
SE
FEN
F DE
SO
ER
E LAY
SIV
C ES
ACCIDENT S UC

Fig. 5.1  The Swiss Cheese model of accident and incident causation. (Source: Professor James Reason by kind permis-
sion to the author)

an incident that killed or harmed a patient be seen drug can provoke a reaction. The surgeon though
as an unfortunate one-off local occurrence with probably thinks less about the propensity for the
no more general lessons to be learned. One of the system, through its design, to make it more likely
major figures from outside healthcare to explain that she will operate on the wrong side of the
this perspective was Professor James Reason body. The physician ordering anticoagulants
from the University of Manchester in England probably thinks more about blood tests and clini-
[14]. He put forward a compelling metaphor to cal monitoring data than the risk of a patient
encourage more broad-based thinking. He com- being given 15,000  units of heparin and killed
pared the risks of an accident or incident to the when the intended dose was 1500  units but the
holes in slices of a Swiss cheese (Fig. 5.1). The abbreviation for “unit” was interpreted by the
solid pieces of cheese are the system’s defences, administering nurse as a zero.
whilst the holes are the weaknesses. The holes in Every day, around the world, patients die and
the slices of James Reason’s Swiss cheese—the are harmed because of these and similar circum-
organisation’s system—open, close, and realign stances. Human error occurs in weak systems:
constantly. Some of the holes or risks are unsafe those that promote error rather than reducing its
actions by individuals: slips, lapses of attention, likelihood. Tomorrow’s practitioners must not
mistakes, or violations of procedure. Many more only think about themselves and their actions.
are due to what Reason calls “latent conditions”. They must also have “systems awareness”.
These things like lack of training, weak proce- It is also vital for health policymakers, health-
dures, and faulty or poorly maintained equipment care leaders (not only clinical staff) to understand
create preconditions for failure. and embrace systems thinking. Frontline aware-
Doctors traditionally have not been trained to ness of systemic weaknesses and risks is impor-
think systemically. Their concern is the patient in tant but so too is strategic awareness by those
front of them. They realise, of course, that their responsible for the infrastructure, organisation,
treatments and decisions can have negative out- and delivery of care for communities and
comes, but their training puts these in the cur- populations.
rency of “complications” or “side effects”. The A system is sometimes a whole healthcare ser-
surgeon knows that her patient can develop post-­ vice. It is also a collection of processes of care
operative bleeding. The physician knows that his within a health facility or care setting. In a large
56 L. Donaldson

hospital, there may be 50 individual service 5.2.2 Culture, Blame,

groups all with their own processes and proce- and Accountability
dures. So, a systems perspective when something
goes wrong, for example, can focus on the factors The implications of system thinking in patient
that led to a nurse inadvertently giving an infant a safety are quite profound. It means that ministries
fatal overdose of a drug intravenously. Or, it of health, managers of health facilities, the media,
might take an even broader view if the problem and the public must accept this paradigm as an
necessitates it. For example, an investigation of explanation for the harm caused and cannot take
high healthcare infection rates might conclude a routinely “off with their heads” approach when
that a group of African hospitals cannot maintain something serious happens. Blaming individuals
clean care because they do not have a source of is common. It is easy, and generally popular.
clean water. As a result, finding a way to cheaply However, it is unfair, counter to developing a
and locally manufacture an alcohol hand rub strong patient safety culture where learning ben-
could help staff reduce infection rates. That efits future patients. It has led many doctors and
would be aligning a systemic cause of harm with nurses who have simply made an honest mistake
a systemic solution. to end up behind bars. The force of public out-
There are good examples of large-scale sys- rage is often too great for the chief executive offi-
temic actions led by clinicians. Global clinical cer of a hospital or health minister to withstand.
networks of specialists and professional bodies Their principles are sacrificed and they take the
are very well placed to identify common high-­ easy way out. The damage to their leadership in
risk situations and galvanise support for action. the eyes of their staff is then incalculable. They
The international clinical movement to reduce did not have the courage to defend the learning
harm from sepsis [15] has shown how raising culture when the chips were down.
awareness and championing the need for action This is one of the most difficult and debated
on a systemic patient safety issue can lead to areas of patient safety and is usually referred to
change in attitudes and practice right across the as the “blame culture” principle. There are many
world. Anaesthetic risk has been much reduced other dimensions to considering culture in rela-
by combined research and action driven by tion to patient safety and the goal of promoting,
organisations in this specialty either nationally, sustaining, and consistently delivering safer care
regionally, or globally. (Fig.  5.2). Also within the culture of organisa-

Fig. 5.2  Patient safety

culture has many strands Open disclosure
(© Sir Liam Donaldson) culture
Non-
hierarchial Data
culture culture

Systems-
Blame-
thinking
free
culture
culture

Patient-
centred Risk awareness
culture culture
Human factors
culture
5  Safer Care: Shaping the Future 57

tions, there are certain behavioural aspects that tudes where a junior nurse dare not challenge a
will place patients at higher risk, including: for senior doctor even if he is behaving unsafely, and
example, an arrogant belief that the organisation ostracising whistle-blowers and others who are
is too good to fail, a tendency to avoid dealing trying to highlight dangers (Fig. 5.3).
with signs that all is not well, hierarchical atti- Modern healthcare is delivered in a complex,
fast-moving environment. With the wrong cul-
ture, together with staff that are unaware of the
potential risks of the care that they are delivering,
then unsafe care may burst through and begin to
kill and harm patients (Fig. 5.4).

5.2.3 Leadership at the Frontline

ARROGANCE
There is a caveat to an entirely systemic view of
DENIAL the world. Other high-risk industries do not set
BLAME aside the need to focus on the individual as well
as the system. This is not to blame them but to
MESSENGER SHOOTING
ensure that they are educated in risk and its
AVERTING GAZE importance, skilled, capable, and conscientious.
HIERARCHIES For example, in the airline industry, the num-
ber of times that an airline pilot might be assessed
PASSIVE LEARNING during their career could be as high as a hundred.
Fig. 5.3  Seven deadly sins: harmful behaviours within Rehearsing in a simulator regularly, somebody
health organisations (© Sir Liam Donaldson) flying with them in the flight deck, having regular

Fig. 5.4  The bulging

triangle: how unsafe
care can break out of its
boundaries (© Sir Liam
Donaldson)
Co
mp
lex
ks
ris

h
igh
of
re

vo
wa

lum
na

es
fu

Unsafe Care
ett
f
Sta

ing

Punitive culture
58 L. Donaldson

medicals, these are part of the process of ensur- ing health leaders, politicians, experts, research-
ing safe air travel. In many parts of the world, ers, and patient representatives into the same
once a doctor has finished training, they may not rooms.
have any regular checks on their performance or
challenges to how they would handle emergency
situations. Simulation is playing an increasingly 5.3.1 P
 atient Safety on the Global
important part in healthcare, particularly in edu- Health Agenda
cation and training. Other industries are much
further ahead in simulating unsafe situations and The World Health Organization (WHO), the
training their staff. It is an exciting idea to develop United Nations agency responsible for health,
skills, away from the patient and then bring the first raised the profile of patient safety to global
practitioner to the patient when they have a higher importance. In May 2002, the 55th World Health
level of skill. It is not the whole solution to creat- Assembly (the annual policy-making meeting of
ing “safety-wise” practitioners. all 192 countries of the world) adopted
One of the great strategic needs in patient Resolution 55.18. This urged Member States to
safety is for leadership, and role models in patient pay the closest possible attention to the problem
safety for young practitioners. There are many of patient safety and to establish and strengthen
wonderful patient safety leaders at global level science-­based systems necessary for improving
and within countries. They have been instrumen- patient safety and the quality of healthcare [16].
tal in making patient safety the priority that it is Following this, in May 2004, the 57th World
today within health systems around the world. Health Assembly supported the creation of an
However, there are far too few of them. Every international alliance to facilitate the development
clinical team in every part of every health system of patient safety policy and practice in all member
of the world needs skilled committed leadership states, to act as a major force for improvement
in patient safety. This is needed because every globally. The World Alliance for Patient Safety, a
patient must be protected from the ever-present partnership between WHO and external experts,
risk of harm. It is here that we can look to the healthcare leaders, and professional bodies, was
young generation of doctors, nurses, and other launched formally in October of 2004.
health professionals who are already demonstrat-
ing their interest and passion for patient safety.
5.3.2 W
 orld Alliance for Patient
Safety: Becoming Global
5.3  lobal Action to Improve
G
Safety The World Alliance for Patient Safety formulated
an initial programme of work framed as a series
Through the early years of the twenty-first cen- of six important actions intended to reduce harm
tury, patient safety began to feature as a priority caused to patients:
or programme of work in larger hospitals in the
higher income countries of the world, and in • The first Global Patient Safety Challenge,
some national health systems. It was still a long focusing, on the theme of healthcare-­
way from the mainstream of healthcare leaders, associated infection [17]
policymakers, and frontline clinical staff. • A Patients for Patient Safety network involv-
Initially, it was a subject very much in the domain ing patient organisations and led by ­individuals
of a small number of thought leaders, research- who had suffered avoidable harm from health-
ers, and enthusiasts. Moving these deliberations care [18]
and debates to global level catalysed action in • A Taxonomy for Patient Safety, ensuring con-
country health systems on a much more extensive sistency in the concepts, principles, norms, and
basis and served a convening function by bring- terminology used in patient safety work [19]
5  Safer Care: Shaping the Future 59

• A Research for Patient Safety initiative to spoke at conferences, always sought to educate
identify priorities for patient safety-related and inform about the concepts and philosophy
research in high-income, middle-income, and that should underlie a modern approach to safety
low-income countries as well as projects and in healthcare.
capacity building particularly aimed at low-­
income countries [20]
• A Solutions for Patient Safety programme to 5.3.3 T
 he Global Patient Safety
identify, develop, and promote worldwide Challenges
interventions to improve patient safety
• A set of Reporting and Learning best prac- As each of the foundation strands of the global
tice guidelines to aid in the design and devel- patient safety initiative began to be implemented,
opment of existing and new reporting they attracted a great deal of interest, involve-
systems [21]. ment, and began to shape change in healthcare
systems around the world.
The overall aims of this global partnership for At the beginning, it had been important to
patient safety were: to promote the development choose a major aspect of patient safety that
of evidence-based norms for the delivery of safer affected all countries of the world and was big
patient care, to create global classifications for enough to warrant intensive action on a global
medical errors, and to support knowledge sharing scale. Healthcare infection fitted these criteria
in patient safety between member states. There immediately. It was endemic within every health-
was also a strong advocacy role to raise aware- care system. In high-income countries, there was
ness of the risks of unsafe care and generate a great concern, not just about the persistence of
better understanding of the reasons why harm the problem, but the emergence of life-­threatening
occurs, to draw attention to the most effective antimicrobial-resistant strains such as methicillin-­
preventive measures, as well as establishing the resistant Staphylococcus aureus (MRSA). In
means to evaluate them. low-income and middle-income countries, the
At the outset, there were three core principles problem was even more serious especially where
that underpinned the initial focus for action at the infrastructure of care was weak.
global level: The first Global Patient Safety Challenge,
aimed to engage the world’s health systems in a
• A commitment to placing patients at the cen- movement to reduce healthcare infection. It
tre of efforts to improve patient safety began by convening all the leading experts to for-
worldwide mulate ground breaking new evidence-based
• A focus on improving ways to detect and learn guidelines on hand hygiene. In addition, a major
from information about patient safety prob- study was mounted to assess the burden of health-
lems within and across countries (with a par- care infection (particularly in low- and middle-­
ticular emphasis on methods and tools for income countries). This first Challenge Clean
detecting patient safety problems in low-­ Care is Safe Care [17] invited health ministers to
income countries) personally, and publicly, sign a pledge to address
• A need to build up the knowledge base of healthcare infection in their countries.
interventions which have been shown to help The first Global Patient Safety Challenge was
solve patient safety problems, together with a the flagship element of the World Alliance for
more rapid and systematic dissemination of Patient Safety’s initiative. It was highly visible
information worldwide on successful and easily understood by politicians, health pro-
strategies. fessionals, and the public. It was relevant to all
countries: rich, poor, and emerging economies.
The World Alliance for Patient Safety, in its Everyone had a vested interest in its success
publications, its events, and when its members because anyone could need treatment in a health
60 L. Donaldson

facility and could therefore become the victim of became available with no patent restriction for
harm by acquiring an infection. local manufacture.
In driving forward Clean Care is Safer Care, a A further key step in achieving the global
wide range of supporting activities and cam- reach of the hand hygiene programme was the
paigns was implemented. The idea of this development of the Five Moments for hand
Challenge generated huge interest and enthusi- hygiene model [23]. This emphasised the points
asm across all six WHO regions. As ministers in the process of patient care when the risks of
signed their pledges in country and regional transmission of an infection by a caregiver’s
launches and events, from a small start, eventu- hands were highest. The Five Moments’ visual
ally, the commitments covered 85% of the image (Fig.  5.5) is striking and easily remem-
world’s population. bered by frontline staff; therefore, it has acted as
The WHO hand hygiene global campaign a technical educational tool that succeeded in
(SAVE LIVES: Clean Your Hands) [22] launched standardising practice worldwide but also it has
in 2009 has been particularly successful. Before become a brand of safety with global spread.
the Challenge, alcohol-based hand rubs (hand Overall, the first Global Patient Safety
sanitisers) were not commonplace in hospitals Challenge represented a proven change model
around the world. The core message was that the that mobilised the world around infection preven-
lack of consistent, immediate, access to a sink tion through: (a) awareness raising about the bur-
equipped with soap and single-use towels (high-­ den of the problem to engage stakeholders; (b) an
income countries) and/or the unavailability of approach to engage nations through demonstra-
clean water (many low-income countries) put ble commitment; (c) the availability of evidence-­
patients at risk. The evidence of higher efficacy, based guidance and implementation tools to drive
effectiveness, and skin tolerability of alcohol-­ improvement.
based hand rubs made them the method of choice The original concept of such a Challenge was
to assure hand hygiene. The Challenge made of a 2-year start-up period, after which responsi-
alcohol hand rubs more affordable to the poorest bility for its continuance would pass to WHO
hospitals of the world by ensuring that the member states and their healthcare systems.
University Hospital of Geneva formulation However, Clean Care is Safer Care generated so

Fig. 5.5  Five moments

for hand hygiene.
RE
(Source: World Health FO N/ASEPTIC
Organization— BE LEA CEDUR
C RO E
reproduced with
P
2

permission)

BEFORE AFTER
1 TOUCHING 4 TOUCHING
A PATIENT A PATIENT
DY

3
RE

AFT O
ER B S
U

FL U I
D E XPO
RIS
K

AFTER
5 TOUCHING PATIENT
SURROUNDINGS
5  Safer Care: Shaping the Future 61

much momentum, passion, and so great a sense • New evidence-based guidelines on injection
of solidarity across the world that the WHO’s safety and ongoing testing of an implementa-
team in Geneva was continuing to play a strong tion campaign in three countries supported by
leadership role 10  years after the launch. This more than 20 new tools
success and the perception of the need for sup- • New evidence-based guidelines for the pre-
porting infection prevention and control improve- vention of surgical site infections based on 27
ment in many countries, led the WHO to institute systematic literature reviews and including 29
a new, formalised infection prevention and con- recommendations
trol global unit. • New evidence-based guidelines on the core
Other important achievements of the first components of effective infection prevention
Challenge and associated global infection pre- and control programmes to reduce harm from
vention and control work included: health care-associated infections and antimi-
crobial resistance
• An assessment of the burden of healthcare
infection in low- and middle-income A second Global Patient Safety Challenge rec-
countries ognised the relatively high burden of disease aris-
• WHO guidelines and 100s of associated ing from unsafe surgical care. Safe Surgery, Saves
publications Lives [24] created a surgical checklist that was
• Fifty-five hospital departments across six piloted, evaluated, and promoted for use globally.
countries demonstrated scientifically Initial evaluations showed that the checklist
successfully implemented a hand hygiene
­ reduced morbidity and mortality associated with
multimodal improvement strategy surgery in early studies of its use. Major profes-
• Over 30 countries established WHO-guided sional bodies across the world endorsed it. It is in
local production of alcohol-based hand rub widespread use in hospitals in many countries
• Over 50 countries ran successful hand hygiene and, increasingly, it is seen as essential if the key
national campaigns risks of surgery are to be avoided. However, the
• Almost 20,000 health facilities in 177 coun- original checklist has been widely adapted whilst
tries joined the WHO SAVE LIVES: Clean the experience of the surgical checklist’s use
Your Hands campaign worldwide has not been formally revisited since
• Global initiatives and engagement of thou- its launch.
sands of health workers around hand hygiene The checklist concept was developed further
every year on 5th May with the creation of the WHO Safe Childbirth
• Patient engagement/information tools issued Checklist [25], which focuses on reducing risk
• Reports from seven global surveys, on hand and adverse outcomes related to childbirth for
hygiene and a range of infection prevention both mothers and babies. Of the more than 130
and control and antimicrobial resistance million births occurring each year, an estimated
priorities 303,000 result in the mother’s death, 2.6 million
• Hand hygiene and infection prevention and in stillbirth, and another 2.7 million in a newborn
control messages embedded in key pro- death within the first 28 days of birth. The major-
grammes of work including antimicrobial ity of these deaths occur in low-resource settings
resistance, WASH and maternal and child and most could be prevented. The WHO Safe
health Childbirth Checklist supports the delivery of
• Alcohol-based hand rub featured in the WHO essential maternal and perinatal care practices
List of Essential Medicines and addresses the major causes of maternal death,
• Guidance produced on infection prevention intra-partum-related stillbirths, and neonatal
and control during the 2014–15 Ebola virus deaths. The Safe Childbirth Checklist
disease outbreak (through the leadership of Collaboration has already made significant
the team) strides to improving maternal and neonatal
62 L. Donaldson

health. It is hoped that the Checklist can become • Partnerships with healthcare providers and
an effective life-saving tool that can be used in a policymakers
wide range of settings. • Influencing and contributing to policy and
research priorities

5.3.4 Patients and Families: The Patients for Patient Safety network now
Championing Change has over 500 advocates, also known as Patients
for Patient Safety champions, in 54 countries.
In addition to the expert reports that had drawn Newsletters are produced quarterly to promote
the attention of policymakers to problem of the sharing of knowledge and experiences.
unsafe care, a powerful driving force for change The champions involved in the Patients for
was the visibility of tragic and harrowing situa- Patient Safety Programme have: acted as advo-
tions in which patients had suffered serious harm cates for the importance of tackling unsafe care
or died. Some of the victims of this unsafe care, in the healthcare systems of their countries; par-
or often surviving family members, had risen ticipated in education and training programmes
above their personal tragedy to tell their stories for healthcare professional staff; supported other
very publicly and call for the world’s healthcare victims of harm who have contacted them; and,
systems to take action. served on boards and advised hospitals on the
The World Alliance for Patient Safety estab- design of their services.
lished the Patients for Patient Safety Programme as The role of patients and family members in
one of its first actions. Susan Sheridan (a contribu- the quest for safer healthcare worldwide has been
tor to this book), whose son suffered brain damage, of incalculable benefit to the advancing the case
and whose husband died, both associated with of patient safety globally in the last decade
medical error, was the first external lead of this pro- (Table 5.2). Their experience, wisdom, and cour-
gramme. Over time, a global network of patient age has fuelled a journey whose eventual end-­
champions was established. Many were themselves point will be a coalescence of compassion and
victims of avoidable harm or they were a parent of learning to eradicate serious harm from every
a child who had died or had been harmed. healthcare system in the world.
With the expanding ageing population, the
rise in non-communicable diseases and ever-­
rising healthcare costs, there is more willingness 5.3.5 African Partnerships
than ever by healthcare providers to engage with for Patient Safety
patients, families, and communities. Recognising
these challenges and opportunities, the Patients African Partnerships for Patient Safety (APPS)
for Patient Safety Programme has restructured [26] was launched in 2009. It was designed to fill
its approach to emphasise four key strategic a perceived gap in patient safety in Africa. It was
objectives: part of a WHO response to the commitment to
strengthen patient safety articulated by 46 minis-
• Advocacy and awareness raising tries of health at the 58th session of WHO’s
• Capacity development and strengthening Regional Committee for Africa in 2008.

Table 5.2  Value of involvement of patients and families who have suffered harm
Role Benefit
Educator Reinforces professional values of caring, compassion, and respect
Storyteller Wins hearts and minds of leaders and frontline staff; stays in the memory
Advocate Gains commitment at wider political, public, and professional levels; initiates campaigns for specific
actions (e.g. for sepsis, for in-patient suicide)
Partner Strengthens design and delivery of future care pathways and patient safety programmes
Reporter Highlights new risks and improvement opportunities
5  Safer Care: Shaping the Future 63

African Partnerships for Patient Safety devel- technical assistance improvement models. It used
oped a multi-country, hospital-to-hospital part- frontline expertise from across both arms of the
nership programme. Initial support came from partnership hospitals with a focus on co-­
the United Kingdom Department of Health. development and relationship building. The tools
Subsequently, the Government of France funded developed by the programme are now being uti-
expansion of the programme beyond English lised across the world, notably through the United
speaking countries. During the period 2009– Kingdom’s Department for International
2014, African Partnerships for Patient Safety Development Health Partnerships Scheme, hos-
oversaw the implementation of 17 hospital-to-­ pital partnership initiatives led by Expertise
hospital partnerships. The partnerships com- France, partnerships supported by the Ministry of
prised European hospitals from three countries Foreign Affairs of Japan, partnerships supported
(France, Switzerland, and the United Kingdom) by the Tuscany region of Italy and a recent major
and hospitals in 17 different countries in the initiative focused on hospital partnerships initi-
WHO African Region (Benin, Burkina Faso, ated by the Ministry of Health in Germany.
Burundi, Cameroon, Côte d’Ivoire, Ethiopia, African Partnerships for Patient Safety illus-
Ghana, Malawi, Mali, Niger, Rwanda, Senegal, trated how frontline passion and energy has
Togo, Uganda, the United Republic of Tanzania, driven implementation of patient safety initia-
Zambia, and Zimbabwe). Linguistic diversity tives through strong human interaction and soli-
was maintained through the involvement of darity across continents. The work has informed
English, French, and Portuguese speaking national policy direction in multiple countries in
countries. the WHO Region of Africa. Importantly, African
As African Partnerships for Patient Safety Partnerships for Patient Safety has shone the
evolved, south–south patient safety partnerships light on the potential for high-income countries
were established between hospitals in Zimbabwe to learn from low-income countries, the so-called
and between Morocco and its partnership hospi- reverse innovation.
tal further south. In addition, a partnership was The work of African Partnerships for Patient
established involving the Johns Hopkins Safety has provided a strong foundation for the
University Armstrong Institute for Patient Safety development of a wider international effort on
& Quality and institutions in three African coun- “twinning partnerships for improvement”. This is
tries (Liberia, South Sudan, and Uganda). particularly relevant given the increasing impor-
African Partnerships for Patient Safety tance placed on quality as part of the fabric of
received widespread international attention and Universal Health Coverage-driven reform pro-
recognition. It illustrated how teams skilled in cesses across the world, and in particular in low-­
infection prevention and control and patient income countries.
safety can act as a bridge between disease-­
specific programmes and health systems. This
strengthens interaction at the health facility level. 5.3.6 T
 hird Global Patient Safety
It provided a very tangible entry point for broader Challenge: Medication Without
improvement in service delivery. Evaluation of Harm
the programme showed gains in hand hygiene
compliance by health workers, implementation The World Health Organization (WHO) launched
of the WHO Surgical Safety Checklist, training its third Global Patient Safety Challenge in 2016
and education of healthcare workers, medication [27]. Its aim is to reduce the global burden of iatro-
safety, healthcare waste management, clinical genic medication-related harm by 50% within 5
audit, teamwork, and leadership. years. The intention is to match the global reach
A defining feature of the African Partnerships and impact of the WHO’s two earlier Global Patient
for Patient Safety approach is that it presented an Safety Challenges, Clean Care is Safer Care and
alternative to traditional vertical, expert-driven, Safe Surgery Saves Lives. The third Challenge,
64 L. Donaldson

Medication Without Harm, invites health ministers 5.3.7 T

 he 2019 WHA Resolution
to initiate national plans addressing four domains and World Patient Safety Day
of medication safety, namely: engaging patients
and the public; medicines as products; education, Further impetus and fresh momentum was
training, and monitoring of healthcare profession- injected into the global patient safety movement
als; and systems and the practices of medication in 2019 when the World Health Assembly again
management (Fig. 5.6). It also commits the WHO considered patient safety. This came at a time
to use its convening and coordinating powers to when, despite efforts of the previous decade,
drive forward a range of global actions. A tool to harm due to unsafe care was recognised as one of
empower patients is already available. the 10 leading causes of morbidity and mortality
Three key areas of medication safety have globally, exceeding malaria and tuberculosis and
been identified as early priorities. They will be level with HIV.
the most visible and public-facing aspects of this In May 2019, the 72nd World Health Assembly
latest Challenge, just as hand hygiene and the designated patient safety as a global health prior-
surgical checklist were the flagship elements of ity; adopted resolution WHA72.6 [28] and estab-
the first two Global Patient Safety Challenges. lished an annual World Patient Safety Day.
They are: high-risk medicine situations; poly- WHA72.6 requests the WHO’s Director General:
pharmacy; and transitions of care. Each is “To emphasize patient safety as a key strategic
­associated with a substantial burden of harm and, priority in WHO’s work across Universal Health
if appropriately managed, could reduce the risk Coverage agenda”, and: “To formulate a global
of harm to large numbers of patients in health patient safety action plan in consultation with
systems across the world. Member States, regional economic integration

Fig. 5.6  Third Global

Patient Safety
Challenge: strategic
framework (© World
Health Organization
2018. Some rights
reserved. This work is
available under the CC
BY-NC-SA 3.0 IGO
licence)
5  Safer Care: Shaping the Future 65

organisations and all relevant stakeholders, 3. Donaldson LJ, Fletcher MG.  The WHO world
alliance for patient safety: towards the years
including in the private sector”. of living less dangerously. Med J Aust.
This major commitment and the delivery of a 2006;184(10):S69–72.
comprehensive action plan will drive the shape of 4. Siddiqi S, Elasady R, Khorshid I, Fortune T,
patient safety programmes across the world for Leotsakos A, Letaief M, et al. Patient Safety Friendly
Hospital Initiative: from evidence to action in seven
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2012;24(2):144–5.
5. Agency for Healthcare Research and Quality
5.4 Conclusions (AHRQ). Advances in patient safety: from research
to implementation. 05-0021. CD ROM.  Bethesda:
AHRQ; 2005.
In an era when the human genome has been 6. European Commission (EC). Report on the member
mapped, when air travel is safer than ever before, states’ implementation of council recommendations
and when information flows across the globe in on patient safety. Brussels: EC; 2012.
7. Organisation for Economic Development and
seconds, patients cannot be reassured that they Cooperation (OECD). Measuring patient safety:
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Firstly, the scale of the problem is so great that 10. Macrae C. Close calls: managing risk and resilience in
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 Patients for Patient Safety
6
Susan Sheridan, Heather Sherman,
Allison Kooijman, Evangelina Vazquez,
Katrine Kirk, Nagwa Metwally, and Flavia Cardinali

6.1 Introduction World Health Assembly (WHA) [3], the policy

setting body for the World Health Organization
The people have a right and duty to participate (WHO), ratified the Global Action on Patient
individually and collectively in the planning and
implementation of their own health care—WHO
Safety [4]. Through this document, the WHA
Alma Ata Declaration (1978) [1] urged Member States to “work in collaboration
with other Member States, civil society organiza-
Unsafe care results in approximately 2.6 mil- tions, patients’ organizations, professional bod-
lion deaths per year. It is one of the top 10 causes ies, academic and research institutions, industry
of death worldwide [2]. Recognizing unsafe care and other relevant stakeholders to promote, pri-
as a growing global burden, in 2019 the 72nd oritize and embed patient safety in all health poli-
cies and strategies” [4]. The WHA further urged
Member States to “put in place systems for the
S. Sheridan (*)
The Society to Improve Diagnosis in Medicine, engagement and empowerment of patients, fami-
Evanston, IL, USA lies and communities (especially those who have
e-mail: [email protected] been affected by adverse events) in the delivery
H. Sherman of safer health care, including capacity building
Patient Safety and Quality Improvement initiatives, networks and associations; and to
Specialists, LLC, Chicago, IL, USA work with them and civil society, to use their
A. Kooijman experience of safe and unsafe care positively in
Patients for Patient Safety Canada, Vancouver, BC, Canada order to build safety and harm minimization
E. Vazquez strategies as well as compensation mechanisms
Patients for Patient Safety Mexico/Pan American and schemes, into all aspects of the provision of
Network for PFPS, Mexico City, Mexico
health care, as appropriate” [4].
K. Kirk Simply stated, the WHA, through The Global
The Danish Patients for Patient Safety,
Copenhagen, Denmark Action on Patient Safety, called for Member
States to democratize healthcare by engaging
N. Metwally
Patients for Patient Safety Champion—Egypt, with the very users of the healthcare system—
Member of the Supreme Council, The Egyptian Red patients, families, and community members—
Crescent, Cairo, Egypt along with other partners—in the “co-production”
F. Cardinali of safer healthcare.
Quality Department, National Agency for Regional In this chapter, I share how preventable harm
Healthcare Services (AGENAS), Rome, Italy
to my son, Cal, from neonatal jaundice, and the
e-mail: [email protected]

© The Author(s) 2021 67

L. Donaldson et al. (eds.), Textbook of Patient Safety and Clinical Risk Management,
https://doi.org/10.1007/978-3-030-59403-9_6
68 S. Sheridan et al.

death of my late husband, Pat, from the failure 6.3 Background: The Genesis
to communicate a malignant pathology, cata- of a Global Movement
pulted me into a global movement of patients, for Co-production
family members, communities, and civil soci- for Safer Care
ety advocating for safer care that became known
as the WHO’s Patients for Patient Safety (PFPS) In 2002, the 55th WHA passed Resolution
Programme (mentioned in the previous chap- WHA55.18 which established “the need to pro-
ter). I along with others around the world who mote patient safety as a fundamental principle of
have experienced harm from unsafe care have all health systems” and resulted in WHO launch-
harnessed our wisdom, our grief, and our anger ing the World Alliance for Patient Safety (now
to courageously partner with passionate thought known as the WHO Patient Safety Programme)
leaders in healthcare including clinicians, [7, 8]. The World Alliance for Patient Safety con-
researchers, policy makers, medical educators, sisted of six action programmes, one of which
and quality improvement experts to co-produce was the Patients for Patient Safety Programme
patient safety initiatives to ensure that our (the PFPS Programme), where I served as the
healthcare systems “learn” from our adverse External Lead for 7 years. The PFPS Programme
events and implement systematic strategies to is a global network of committed patients, fami-
reduce risk of harm. The real-world examples lies, healthcare professionals, and policy makers
of co-production within this chapter demon- who are connected by the common objective of
strate the important role of civil society as well promoting safer care through patient involve-
as how patients, families, and communities ment. They bravely advocate for and collaborate
“that have experienced adverse events can use in patient safety efforts at the local, national, and
their experience of safe and unsafe care posi- international levels [9]. These individuals, known
tively in order to build safety and harm reduc- as PFPS Champions, teach, offer hope and pro-
tion strategies” in developing and developed vide inspiration. They have organized as individ-
countries [4]. uals, networks, patient associations/organizations
and in discrete patient programs within estab-
lished public and civil society structures. Their
6.2  hat is Co-production
W dedication to co-producing safer healthcare is
in Healthcare? guided by the seminal document, the London
Declaration, which was authored by representa-
Co-production is the “interdependent work of tives from 21 countries who had experienced
users and professionals to design, create, develop, harm directly or indirectly as a result of unsafe
deliver, assess and improve the relationships and care. The London Declaration calls for partner-
actions that contribute to the health of individuals ship and the democratization of healthcare to
and populations through mutual respect and part- improve patient safety:
nership that notices and invites each participant’s The London Declaration
unique strengths and expertise” [5]. Co-produced We, Patients for Patient Safety, envision a different
patient safety initiatives are “mutually benefi- world in which healthcare errors are not harming
cial…at every level and in every health-related people. We are partners in the effort to prevent all
avoidable harm in healthcare. Risk and uncer-
endeavor, from designing educational curricula tainty are constant companions. So, we come
to setting research priorities to hiring faculty and together in dialogue, participating in care with
leadership to operating health organizations” [5]. providers. We unite our strength as advocates for
Patients are not viewed as “‘users and choosers’ care without harm in the developing as well as the
developed world.
but as ‘makers and shapers’ [which] allows for We are committed to spread the word from person
planning and implementing new policies that can to person, town to town, country to country. There
potentially lead to better health outcomes and is a right to safe healthcare and we will not let the
patient experiences” [6]. current culture of error and denial, continue. We
6  Patients for Patient Safety 69

call for honesty, openness, and transparency. We neonatal jaundice (hyperbilirubinemia), known
will make the reduction of healthcare errors as a
basic human right that preserves life around the
as kernicterus. After determining that a pre-­
world. discharge bilirubin test would have helped pre-
We, Patients for Patient Safety, will be the voice vent our newborns from suffering, mothers of
for all people, but especially those who are now children with kernicterus formed a nonprofit
unheard. Together as partners, we will collabo-
rate in:
organization (civil society), Parents of Infants
and Children with Kernicterus (PICK) [12]. The
• Devising and promoting programs for PICK Board of Directors, comprised of the moth-
patient safety and patient empowerment. ers, had two specific goals: (1) co-design a safer
• Developing and driving a constructive dia- healthcare system for newborns to include a uni-
logue with all partners concerned with
patient safety. versal, pre-discharge bilirubin test; and (2) co-­
• Establishing systems for reporting and design materials to empower parents with
dealing with healthcare harm on a world- information. While the healthcare providers were
wide basis. sympathetic to these mothers, healthcare leaders
• Defining best practices in dealing with
healthcare harm of all kinds and promoting stated clearly that changes to care or educational
those practices throughout the world. materials could not be made based solely on
anecdotes; evidence-based research was neces-
In honor of those who have died, those left dis- sary. PICK partnered with leading published
abled, our loved ones today and the world’s chil- researchers on neonatal jaundice, treating clini-
dren yet to be born, we will strive for excellence, so
that all involved in healthcare are as safe as pos- cians and patient safety experts to engage in
sible as soon as possible. This is our pledge of developing the evidence necessary to revise clini-
partnership [10]. cal guidelines to include a universal newborn
bilirubin test and revised parent education mate-
By co-producing patient safety initiatives, the rials to empower parents to help prevent future
PFPS Programme, PFPS Champions, and harm to newborns from elevated bilirubin levels.
Member States democratize patient safety and Through the collaboration with the researchers,
fulfill the promise and potential of the directives the PICK mothers helped to collect and donate
stated in both the London Declaration and the clinical data of 125 newborns who were dis-
WHA Global Action on Patient Safety. charged as healthy from the place of birth but
subsequently sustained kernicterus. The collec-
tion of data became known as the Pilot USA
6.4 Co-Production in Research Registry of Kernicterus [13]. PICK formed the
Kernicterus Prevention Partnership Coalition that
There is growing awareness that patient engage- included various governmental agencies, aca-
ment in health research is not only ethically impor-
tant, but leads to evidence for developing the most
demic institutions, and other stakeholders. These
effective interventions, policy and practice recom- organizations were unified by a nonbinding
mendations, and planning for ongoing research memorandum of understanding. PICK and the
[11]. researchers partnered with a leading public health
agency to fund and analyze the data, the results of
which indicated that kernicterus was an emerging
6.4.1 Example: United States public health issue and that implementation of a
universal bilirubin (jaundice) test would help
6.4.1.1 Mothers Donating Data: Going identify newborns at risk of hyperbilirubinemia
from Research to Policy and reduce the number of cases of kernicterus.
to Practice PICK also partnered with a leading healthcare
My son, Cal, and other newborn babies suffered system with a large data set of clinical informa-
from preventable brain damage in the United tion on newborns. Analysis of their data also sup-
States as a result of the failure to test and treat ported the implementation of a universal bilirubin
70 S. Sheridan et al.

test. A separate governmental health agency also nicians, and leadership in government agencies,
partnered with PICK to fund the co-production, research institutions, medical education, and
testing and the usability of parent education healthcare systems who willingly partnered with
materials in different populations about the risks the mothers, despite criticism from peers. The
of newborn jaundice and included proactive steps healthcare leaders voluntarily helped the mothers
they could take to identify and prevent harm to gain capacity to be effective advocates for
their newborns [14]. changes in jaundice management protocols. They
The outcome of PICK’s co-production in helped educate the mothers about the structure of
research contributed to the revision of clinical the healthcare system, the responsibilities of the
practice guidelines to include a universal pre-­ various decision-making bodies, the current sci-
discharge bilirubin test [15] and the dissemina- ence and evidence base for management of new-
tion of a “Sentinel Event Alert” by a national born jaundice and gaps in the literature. They
hospital accreditor with recommendations on provided guidance and tips on successful story-
newborn jaundice management [16], established telling and public speaking skills, partnered as
kernicterus as a “Never Event” per a national presenters at national conferences and in inter-
quality measures organization, developed a views with media and provided resources, infra-
national parent education campaign [14] and structure and credibility that facilitated the
materials and co-developed and co-delivered cur- development of the necessary evidence for suc-
ricula for continuing medical education courses. cessful implementation of a systems-based
There were many factors that contributed to approach to the prevention of kernicterus.
PICK’s achievements. One of the key factors was
that a major national government agency invited 6.4.1.2 Civil Society: Driving Patient-­
stakeholders, including patients, to publicly com- Centered Research to Prevent
ment at a National Summit on Medical Errors Diagnostic Errors
and Patient Safety. The organizers of this summit Researchers estimate that up to 80,000 deaths per
offered guidance to those unfamiliar with public year in US hospitals can be attributed to some
comment how to best craft their testimony. At form of diagnostic error. Misdiagnosis affects 12
that summit, I, testified about the preventable million Americans in ambulatory care settings
harm that my son had suffered from undiagnosed annually. The National Academy of Medicine’s
and untreated neonatal jaundice and advocated 2015 report, Improving Diagnosis in Health
for collaboration amongst all stakeholders to pre- Care, highlights the urgent need for a research
vent future cases. Another success factor was the agenda on the diagnostic process and diagnostic
determination, persistence, and relentless call for errors and states that “patients are central to the
action from the community of mothers with chil- solution” and there is a need to “establish part-
dren with kernicterus who formed a respected, nerships with patients and families to improve
independent, nonprofit organization with by-laws diagnosis [17]. The Society to Improve Diagnosis
and objectives to prevent harm to future new- in Medicine (SIDM), where I serve as the
borns through a model of partnership. Further Director of Patient Engagement, is a US-based
these mothers served as a “living repository” of nonprofit organization (civil society) dedicated to
clinical data for research regarding kernicterus reducing diagnostic errors. We believed that if
unavailable through traditional data collection researchers joined forces with trained patients
methods and were the conduit to collecting addi- and family members with lived experience in
tional data from mothers across the world with diagnostic error to co-produce diagnostic safety
children with kernicterus. This enabled the research projects, the research questions and out-
researchers to actively collaborate with the moth- comes would be more relevant, effective, and
ers as subject matter experts. As a result of these patient centered. SIDM pursued funding from the
factors, deep, trusting, mutually beneficial rela- Patient-Centered Outcomes Research Institute
tionships formed with patient safety experts, cli- (PCORI) to (1) recruit patients and family mem-
6  Patients for Patient Safety 71

bers who had experienced diagnostic error and to support sustainability. Patients and family
diagnostic safety researchers to co-develop a members from national disease groups who have
curriculum that provides patients and family
­ firsthand experiences with diagnostic error were
members with the knowledge, skills, and tools to invaluable in identifying research questions and
effectively partner in the design, execution, and topic suggestions that often went unrecognized
dissemination of diagnostic research; and (2) col- or unconsidered. The project developed and
lectively co-produce patient-centered research delivered an innovative, patient-centered training
topics and questions to pursue to improve diag- curriculum that enabled patients and family
nosis [18]. members to effectively distill their personal sto-
SIDM collaborated with Project Patient Care, ries of diagnostic error and participate as true
an independent nonprofit organization of patients, partners in the development of research ques-
family members, and patient advocates and the tions. Because of its success, the curriculum has
Medstar Institute for Quality and Safety to help been replicated in other training efforts in acute
recruit the patient and family participants and to care settings and methods and tools from the cur-
develop the curriculum. I led the project that riculum have been shared nationally and interna-
included patients and family members from key tionally as an approach to engage patients, family
disease-related organizations and representatives members, and other stakeholders in diagnostic
from Patient and Family Advisory Councils improvement efforts [19].
(PFACs) at major healthcare institutions—all
who had experienced diagnostic error. Prominent
diagnostic researchers from academic medical 6.5 Co-production in Medical
centers also participated in the project. Together Professions Education
with the project team, the patients and research- Courses
ers co-produced an innovative, patient-centered
curriculum. This curriculum was continuously Patient engagement is a promising avenue in the
area of healthcare education. Having real patients
evaluated and refined to ensure patient engage- articulate their experiences and viewpoints helps
ment in diagnostic research. Applying the knowl- those taking part in training to appreciate the
edge and methods developed in the curriculum, patient perspective and the importance of preserv-
patients and researchers co-produced a list of ing trust between clinicians and patients. These
core values are essential to care that is compas-
patient-centered diagnostic research topics and sionate, quality assured and, above all, safe.
questions for future research. One of these resul- Exposure to patient stories during training is valu-
tant research questions focused on disparities in able and helps to motivate practitioners to improve
diagnosis due to visible factors of age, sex, and safety [20].
race/ethnicity. This project was awarded funding
There is evidence that teaching by patients has a
for a 2-year research project to be led by SIDM lasting impact in the areas of technical skills inter-
and a major academic institute. personal skills, empathic understanding, and
The promising results of SIDM’s project are developing an individualized approach to the
due to several factors. SIDM is an established patient [21].
nonprofit organization (i.e., a civil society organi-
zation) that has embedded patient and family
engagement as a strategic priority in its mission 6.5.1 Example: Mexico
and dedicated resources to employ a PFPS
Champion as a full-time Director of Patient 6.5.1.1 Leveraging a Regional Network
Engagement. Having SIDM develop and lead this of PFPS Champions to Enhance
project provided the credibility to secure funding Medical Education
from a large national research institute to support According to a study on patient safety in Latin
staff, the patients, family members, researchers, America (IBEAS), “on any given day, 10% of the
leadership, as well as an infrastructure designed patients admitted to the hospitals… had experi-
72 S. Sheridan et al.

enced some kind of harm due to health care” sonal devotion, fervor, and effective networking
[22]. Evangelina Vazquez Curiel [23], a PFPS in advocating for safer care. Because of her
champion and single mother in Mexico whose capacity to understand and appreciate the chal-
newborn son experienced harm soon after birth, lenges of healthcare, and with the credibility of
along with other patients, family members and being a PFPS champion, Ms. Vazquez Curiel
healthcare professionals in Latin America, identi- developed trusting relationships with healthcare
fied the lack of patient safety education for leaders in Mexico, the Pan American Health
healthcare professionals in Latin America as a Organization (PAHO), and other patient leaders
major contributing factor to unsafe care. She and advocates in the Americas. Another contrib-
actively collaborated with academic institutions uting factor in the co-production and popularity
in Mexico, the local Ministry of Health and the of the online course was the Pan American
Pan American Network of PFPS champions to Network of PFPS which is an informal group of
co-produce an online patient safety course for like-minded, patients, family members, health-
healthcare professionals in Latin America that care professionals, and policy makers with simi-
would bring patient safety experts, patients, and lar goals and experiences in patient safety that
healthcare professionals from various healthcare spans 10 countries in the Americas. This network
systems together. Course co-developers, educa- was formed as a result of PAHO/WHO sponsored
tors, patients, speakers, and learners are from PFPS workshops. Its goals are to promote patient
eight countries—Mexico, Costa Rica, Peru, participation in efforts to improve quality and
Paraguay, Uruguay, Ecuador, Chile, and safety in healthcare and to improve patient skills
Columbia. The objectives of the course are to (1) for dialogue with healthcare planners and policy
continuously train healthcare workers from makers. The formation of the regional network
remote and low-resource settings about patient has resulted in a vibrant, connected, multi-­
safety and quality; (2) bring patient safety experts stakeholder regional community that shares best
from across the Latin American region together practices and risk mitigation strategies [27].
to serve as educators and discussion leaders; (3) Finally, this course would not have succeeded
raise awareness of health literacy and highlight without the volunteer healthcare professionals’,
the role it plays in preventing adverse events; and academic institution leaders’, and educators’
(4) encourage dialogue between patients, family willingness to collaborate with the PFPS commu-
members, civil society, and healthcare providers/ nity to co-produce a novel curriculum on patient
treating professionals to reduce power imbal- safety that fosters a transparent, safe environment
ances. The curriculum is comprised of 11 mod- for dialogue about learning from unsafe care.
ules, three of which focus on the WHO Global
Challenges (Clean Care is Safer Care [24], Safe
Surgery [25], and Medication without Harm 6.5.2 Example: Denmark
[26]). The remaining eight focus on the funda-
mentals of improving patient safety and quality 6.5.2.1 Patients as Educators
of care. At the end of the patient safety course, Communication breakdowns at crucial moments
participants receive a certificate from The in the provision of healthcare were leading to
University of New Mexico of Tula. serious adverse events, including death, in Danish
Over 2000 healthcare professionals from a hospitals. The Danish Society for Patient Safety,
myriad of socio-economic backgrounds, practic- a civil society organization and member of the
ing in rural public hospitals to small and large WHO PFPS Programme [28], organized The
private hospitals have participated in the online Danish Patients for Patient Safety (The Danish
course. The course was launched in 2016 and PFPS), a network of volunteer patients and/or
continues to be offered in 2020. family members who had experienced severe
The success of the online patient safety course medical harm as a result of communication fail-
was primarily due to Ms. Vazquez Curiel’s per- ures, to actively address this issue. The Danish
6  Patients for Patient Safety 73

PFPS group believed that (1) effective communi- transform their personal stories of unsafe care
cation between patients, family members, and into learning opportunities coupled with the
healthcare providers was desperately lacking at receptiveness of the Head of Training and the
crucial moments in the provision of care and that Curriculum Coordinator for residents in the capi-
this failure to communicate lead to the serious tal region of Denmark who valued the inclusion
medical errors; and (2) patients and/or family of patient storytellers as viable “teachers” for
members who had been affected by adverse medical residents. Together they thoughtfully
events sharing their real-world learning through structured the storytelling session to optimize
storytelling would be an impactful method of resident learning while reducing concerns of
teaching residents communications skills. Danish those instructors trained in traditional, evidence-­
PFPS champions collaborated with medical lead- based teaching methods. Another factor of the
ers and educators in different regions of Denmark success of the adoption of the storytelling course
to co-produce and fully implement a live story- was the ongoing support and capacity building
telling session as part of the compulsory three-­ for the PFPS Champions that included presenta-
day communication skills course [29]. During the tions skills training offered by the Danish Society
storytelling sessions, a patient or family member for Patient Safety. It was critical for the PFPS
from the Danish PFPS described his/her experi- Champions to learn how to constructively craft
ence with medical error in a manner that high- and share their stories in a way that would result
lighted the points in care where the doctor’s in meaningful learning for the residents without
communication skills, both good and poor, were being perceived as adversarial. The Danish PFPS
especially important to the outcome of the care. Network hopes to spread the idea of patient sto-
Immediately after the Danish PFPS champion rytelling in communications training to the rest
completed his/her story, the storyteller and com- of Denmark and to systematically analyze the
munication course instructor guided the medical long-term impact and effectiveness.
residents through a structured reflection process.
The medical residents were then asked to think
about what they could learn from the story and 6.6 Co-production in Healthcare
how they might incorporate these lessons into Organization Quality
their clinical work. Improvement
To date, approximately 2500–2800 medical
residents have completed the workshop. Medical Hospitals are increasingly recognizing the crucial
role of patients’ perspectives in establishing a cul-
residents consistently share that they have a ture of safety. Many institutions have prioritized
greater appreciation of what the patient or family engaging patient representatives in the design and
member experienced and have a better under- nurturing of safety efforts and emphasize transpar-
standing of why truly listening to patients and ency in reporting errors and care problems [30].
family members is essential to provide safe and
appropriate care. This feedback validated that
live storytelling by patients and/or family mem- 6.6.1 Example: Egypt
bers is an effective method to explore the human
experience of care. As a result, the session has 6.6.1.1 Improving Disparities in Care
been permanently integrated into the regional for New Mothers: The Power
standard curriculum for the medical resident of Partnership Between a Civil
communications training course since 2012. Society Leader and a Public
The successful integration of the live storytell- Teaching Hospital
ing session into the residents’ communication There were significant disparities between the
course is due to the resolve and determination of level of care provided to women delivering
Ms. Katrine Kirk, who experienced an adverse babies in Cairo at the public maternity teaching
event herself, and the Danish PFPS network to hospital versus the private hospital. An Egyptian
74 S. Sheridan et al.

member of The Red Crescent, a civil society ers as part of the hospital team as well as mean-
organization, Nagwa Metwally, now a PFPS ingful hospital-level policy changes. For example,
champion, along with other concerned commu- policy change affected the hospital’s promotion
nity members believed that by integrating local policy for nurses. The criteria for promotion are
volunteer citizens into the hospital system to now based on efficiency, skill, and education
observe and document quality and safety issues rather than seniority only. The hospital also
would help improve the quality of care and expe- implemented a new evaluation criterion for medi-
riences of mothers at the public maternity teach- cal residents to advance to medical doctors. The
ing hospital [31]. Ms. Metwally met with the medical school adopted a doctor/patient relation-
Dean of the medical schools and described the ship skills evaluation as part of the clinical skills
mission of the proposed quality improvement final examination that medical residents must
project. She later met with the Director of the take to become doctors. In addition, there was an
public teaching maternity hospital. During this overall increase in awareness of patient safety
meeting, she thoughtfully and strategically issues, improved hospital cleanliness, as well as a
described the envisioned quality improvement greater use of gloves and hand hygiene practices
project and positioned the project as an “offer to [32]. The success of the quality improvement in
help” and an opportunity for collaboration. This the maternity hospital enabled Ms. Metwally to
resulted in a partnership at the public maternity co-produce similar quality improvement projects
teaching hospital that embedded citizen volun- in geriatrics and emergency hospitals.
teers in the hospital to help improve quality hos- Numerous factors contributed to the success
pital services through observation. The goals of of this co-produced quality improvement effort at
the project included (1) change the culture to be the public maternity teaching hospital. The
more patient centered; (2) ensure dignity and resolve and profound humanitarian commitment
proper treatment for mothers; (3) create a safe by Ms. Metwally and the Red Crescent of which
environment in which mothers felt they could she was a member, was crucial to highlighting
share their preferences and request and receive the need to improve the equity, patient centered-
parent education; and (4) provide capacity build- ness, and patient safety for new mothers in the
ing to the healthcare team, especially nurses, for community. Having the backing of a credible,
the provision of safer and more compassionate trustworthy civil society organization helped
care for the new mothers. Ms. Metwally and citi- facilitate the connection with the leaders of the
zen volunteers joined the hospital team as medical schools and the hospital. Furthermore,
observers to serve as an “extra set of eyes” to framing the quality improvement project as a
identify and record issues related to the WHO’s “way to help out” as well as demonstrating empa-
Global Patient Safety Challenges [24–26] and thy by acknowledging the challenges that the
the WHO’s patient safety curriculum, which public hospital faced was key to developing a
included hospital cleanliness, safe surgery, trusting, respectful collaborative relationship.
healthcare provider behavior, glove use, hand The willingness of the Dean of the medical
hygiene practices, staff and patient interaction, schools and the Director of the maternity hospital
and other safety issues. Over 50 citizen volun- to partner with Ms. Metwally, the Red Crescent
teers and some residents served as observers and citizen volunteers to implement an innova-
conducting walking “tours” within the hospital tive approach to quality improvement demon-
noting and documenting safety and care con- strated the courage, humility, integrity, and
cerns which they would later share with the open-mindedness needed from strong leadership
Director of the hospital for consideration for to realize the benefits of this type of collabora-
improvement efforts. tion. Despite the fact that none of the partners in
Successes of the quality improvement project this active collaboration had previous training in
included the acceptance of these citizen observ- implementing a co-produced quality improve-
6  Patients for Patient Safety 75

ment project such as this, they were resourceful ness, especially in the larger hospitals [33].
and successful because of their trust in each other Where new assessments have been carried out in
and in the belief that their mutual goal was in the 2019, there have been significant reports of
best interest of all in involved, was patient cen- improvements in all four areas of interest. This
tered and improved safety and quality. Italian national program has shown the effective-
ness of co-production of a quality improvement
initiative that actively engaged organizations,
6.6.2 Italy professionals, and citizens to promote patient
centeredness.
6.6.2.1 Democratizing Healthcare: A major component of success of the national
A Government-Driven/Citizen program to improve person centeredness was the
Partnership to Improve Patient strong leadership at AGENAS that was dedicated
Centeredness to and valued the inclusion of citizens as partners
The Italian National Agency for Regional Health in the quality improvement initiative. Examples
(AGENAS) launched a government-driven of this included actively engaging citizens in all
healthcare organization quality improvement phases of the assessment and improvement cycle,
project co-produced with civil society organiza- as well as providing feedback and publicly dis-
tions and citizens. The national program was seminating project results. Another component of
aimed at evaluating and improving the level of success was the strategic partnerships that
patient centeredness in public and private hospi- AGENAS developed to maximize outreach to the
tals throughout the country. AGENAS developed citizen community. They formed strong alliances
an innovative participatory evaluation methodol- with the regional governments and health agen-
ogy. The methodology was coordinated by cies and partnered with Active Citizenship
AGENAS and carried out in cooperation with the Network, the association with the widest exper-
Active Citizenship Network and the Italian tise in the civic evaluation of quality of health. A
Regions. AGENAS trained teams of healthcare further component of success was the national
professionals and citizens to go on site visits in program’s commitment to providing training and
public and private hospitals. During the site vis- capacity building to the citizens and other partici-
its, these teams completed a checklist comprised pants to optimize engagement by developing
of 142 items exploring four areas of interest: joint training on materials and tools of the partici-
person-oriented processes, physical accessibility patory assessment of person centeredness. The
and comfort, access to information and transpar- participatory evaluation methods and tools were
ency, and patient–professional relationships. then applied to assess patient safety. The success
Following the site visits, the data was collected of the national program has led to further imple-
and sent to a National Database where it was ana- mentations of this type of active collaboration
lyzed and sent back to the regions, hospitals, and between government, healthcare professionals,
teams for local public dissemination. civil society organizations, and citizens to co-­
Improvement plans were jointly identified and produce healthcare organization quality improve-
carried out by hospital professionals and citizens. ment projects.
A Plan-Do-Check-Act process was then carried
out by local teams. Over 400 accredited public
and private hospitals participated in this national 6.7 Co-Production in Policy
evaluation. Site visits were made by the trained
teams comprised of approximately 600 health Patient and family engagement in policy develop-
ment has gained increasing recognition. For exam-
professionals, 300 citizen associations, and 700 ple, patients can be engaged in the development
citizens. The overall results of the project indi- and dissemination of tools, information and educa-
cate a moderately high level of person centered- tional materials [20].
76 S. Sheridan et al.

6.7.1 Example: Canada Framework is implemented, adopted by health

systems, and as its impact is evaluated.
6.7.1.1 Working from Within: The success of PFPSC and CPSI and the co-­
Co-producing National Policy production of patient safety policy improvement
as an Insider efforts is largely due to the integration PFPSC
In Canada, unintended patient harm occurs every into the organizational structure of CPSI as well
1 min and 18 s throughout the healthcare system, as the trust and respect that has been developed
with a death resulting every 13 min and 14 s. To by having a shared commitment to patient safety
address this growing concern, Patients for Patient and healthcare system improvement.
Safety Canada (PFPSC) [34], a patient program CPSI made patient engagement a strategic pri-
under the Canadian Patient Safety Institute ority and supported the development of a
(CPSI) [35], a publicly funded, not for profit cor- Canadian network of patients and family mem-
poration and designated WHO Collaborating bers which resulted in the formation of
Centre in Patient Safety and Patient Engagement, PFPSC. CPSI assigned a budget and staff to sup-
has co-produced seminal documents that influ- port PFPSC and patient engagement. CPSI part-
ence policy at the national level on patient safety. ners with PFPSC in all of its programs,
These include the Canadian Disclosure committees, and corporate initiatives, including
Guidelines [36], Canadian Incident Analysis executive recruitment and strategic planning.
Framework [37], Engaging Patients in Patient This structure is mutually beneficial in that it
Safety—a Canadian Guide [38], and Five allows PFPSC to leverage CPSI resources, corpo-
Questions to Ask About Your Medications [39]. rate functions and staff expertise and time, and it
More recently, PFPSC was engaged in the co-­ provides PFPSC credibility, increasing their
production of the Canadian Quality and Patient opportunities to integrate the perspective of the
Safety (CQPS) Framework, a joint initiative patient community into national patient safety
between CPSI and the Health Standards improvement efforts. Alternatively, CPSI, bene-
Organization (HSO) [40]. The framework was fits from PFPSC participation as subject matter
designed by a multi-stakeholder Advisory experts with lived experience of harm from
Committee, including patient and family mem- unsafe care on which to base patient safety
bers of PFPSC, with the specific aim to “establish policy.
consensus on quality and patient safety goals for The leadership and patient-centered culture of
health and social services to focus action and CPSI were fundamental building blocks for suc-
resources that improve patient experience and cessful partnership and integration of patients
outcomes and reduce care variation” [41]. into the work of the Institute. Equally, the tenac-
Members of PFPSC have been active partici- ity of the PFPSC patients and family members in
pants in the development and socialization of the advocating for patient needs and the willingness
CQPS Framework from the outset, as equal play- to adapt within a structured environment were
ers, and regarded as experts through their lived necessary for sustainability and co-production of
experience and patient advocacy. PFPSC seminal documents and policy projects.
Co-Chairs served on the governance Steering
Committee and Evaluation Working Group. An
independent public affairs firm was commis- 6.8 Conclusion
sioned to provide public consultation; an oppor-
tunity for all stakeholder groups to provide input Patient safety is a growing global concern.
into the CQPS Framework. This independent Parents, daughters, sons, siblings, other family
evaluation demonstrated that collective impact members, community members, and our dear
initiatives, co-designed and co-led by patients as friends are harmed unnecessarily from unsafe
authentic partners, can be transformational. This care. It is essential that all stakeholders, espe-
collaborative work will continue as the cially those who have suffered from adverse
6  Patients for Patient Safety 77

events, have the opportunity to actively collabo- • for patients, families and communities to
rate in co-producing patient safety solutions. help them develop the skills to effectively
Those who have experienced adverse events share their personal stories of unsafe care
identify gaps in safety and quality and offer wis- that captures the hearts and minds, builds
dom, data, and stories unavailable through tradi- trust and prompts action from the audi-
tional sources. Each of these case studies ences and to have productive dialogue with
illustrates the power and potential of co-­ healthcare leaders including policy mak-
production with patients, families, and communi- ers, researchers, medical educators and
ties in research, medical professions education, quality improvement experts,
healthcare quality improvement and policy. Each • for healthcare professionals and leaders
is different in scope, structure, and purpose and to learn how to utilize effective patient-­
engage different stakeholders at different levels centered methods to collaborate, commu-
yet they all highlight the necessary building nicate with, listen to and engage with
blocks for co-production of patient safety initia- patients, families and community members
tives and each responds to the call made in the in a democratic way.
London Declaration, the WHO PFPS Programme, 4. Structure that establishes how patients, fami-
and the WHA to place patients at the center of lies and communities operate to obtain their
efforts to improve patient safety. goals. There is no one structure that is consid-
The building blocks include: ered the gold standard for the organization of
patients, families and communities. Structures
1. Dedicated, resilient patient, family, and may be formal or informal. Informal structures
community members who have directly or tend to be loosely organized, autonomous, vol-
indirectly experienced unsafe care yet are unteer patient networks that collaborate with
willing to partner with healthcare decision-­ healthcare professionals, leaders and organiza-
makers and learn how to navigate the com- tions. More formal structures tend to be estab-
plexities, structures and limitations of different lished patient organizations and associations
healthcare systems. They have become which operate independently from the health-
accomplished storytellers, networkers and care system or government such as civil soci-
connectors and have gained appreciation of ety organizations. Finally, there are publicly
the many challenges that healthcare providers funded structures that embed patients, family
and leaders face while remaining unwilling to and community members into their strategic
accept the status quo. plans, budgets and activities necessary to
2. Courageous, passionate healthcare leaders achieve organizational goals. Whether formal
with the moral imperative to integrate the or informal, it is essential that the structure
patient/citizen community into patient safety preserves the values, preferences and out-
improvement efforts. These leaders are vision- comes that matter most to patients, families
aries who visibly demonstrate their commit- and communities and that these serve as over-
ment to listen and learn from others. They arching principles that guide the actions and
value the input from others as highly as their priorities of the safety initiatives. It is also
own and integrate what they learn into gover- important that the structure facilitates access
nance, missions and strategies that promote for patients, families and community members
patient involvement. They hard-wire the nec- to healthcare decision-makers as well as finan-
essary resources to overcome political, cul- cial and human resources to systematically
tural and financial barriers into budgets and analyze the outcomes of co-produced safety
infrastructures that support patient initiatives to improve, scale and spread, or dis-
participation. seminate the benefits of implementation and to
3. Capacity building opportunities ensure sustainability.
78 S. Sheridan et al.

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 Human Factors and Ergonomics
in Health Care and Patient Safety 7
from the Perspective of Medical
Residents

Pascale Carayon, Peter Kleinschmidt,
Bat-­Zion Hose, and Megan Salwei

7.1 Introduction Two other reports also published in 2018 draw

attention to patient safety challenges and gaps in
Health care is about people with various roles health care quality around the world [2]. Systems
(e.g., patient, caregiver, clinician) who interact approaches have been recommended to address
and collaborate in connected care processes of these complex health care quality and patient
diagnosis, treatment, monitoring, and manage- safety problems [1, 3], as well as to improve
ment. Ensuring that these processes produce work systems and working conditions for clini-
“good” outcomes for patients (e.g., quality of cians [4].
care, patient safety, positive patient experience) The discipline of human factors (or ergonom-
as well as for clinicians involved in their care ics) (HFE) provides systems concepts and meth-
(e.g., quality of working life of clinicians) ods to improve care processes and outcomes for
remains a major challenge around the world. The patients, caregivers, and clinicians. According to
US National Academies’ report on Crossing the the International Ergonomics Association, HFE
Global Quality Chasm [1] indicates that inappro- is “the scientific discipline concerned with the
priate and unsafe care remain widespread around understanding of interactions among humans and
the world. In particular, “between 5.7 and 8.4 other elements of a system, and the profession
million deaths occur annually from poor quality that applies theory, principles, data and methods
of care in LMICs for … selected set of conditions to design in order to optimize human well-being
…, which represents between 10% and 15% of and overall system performance” [5]. According
the total deaths in LMICs … in 2015” (page S-2). to this definition of HFE by the IEA, people are at
the center of (work) systems; systems and their
P. Carayon (*) elements and interactions should be designed to
Department of Industrial and Systems Engineering, support performance and enhance well-being of
Wisconsin Institute of Healthcare Systems people. HFE emphasizes the physical, cognitive,
Engineering, University of Wisconsin-Madison,
Madison, WI, USA and organizational dimensions of work systems.
e-mail: [email protected] Medical residents are key stakeholders in deliv-
P. Kleinschmidt ery of high-quality, safe care; they are often at the
UW Health, Madison, WI, USA center of work systems that deliver care to
e-mail: [email protected] patients in hospitals, primary care or specialty
B.-Z. Hose · M. Salwei care facilities, emergency departments, and other
University of Wisconsin-Madison, care settings. Therefore, it is important to design
Madison, WI, USA
the work system of medical residents to improve
e-mail: [email protected]; [email protected]

© The Author(s) 2021 81

L. Donaldson et al. (eds.), Textbook of Patient Safety and Clinical Risk Management,
https://doi.org/10.1007/978-3-030-59403-9_7
82 P. Carayon et al.

quality and safety of care. The discipline, described the work of residents in intensive care
approaches, and methods of HFE can help to units (ICUs), including adult, pediatric, medical,
achieve this goal. and surgical units. Prior to conducting observa-
tions, researchers developed a list of 17 tasks
(e.g., direct patient interaction). Four human fac-
7.2  pplication of SEIPS Model
A tors engineers observed residents in multiple
to Medical Residents ICUs for a total of 242  h. Observers recorded
time spent by residents in the following catego-
The SEIPS (Systems Engineering Initiative for ries: (1) direct patient care (e.g., clinical review
Patient Safety) model [6, 7] is an HFE systems and documentation), (2) care coordination (e.g.,
model that can be used to describe the work of conversation with team physician), (3) indirect
medical residents and its impact on patient safety patient care (e.g., administrative review and doc-
and resident outcomes, such as well-being, safety, umentation), and (4) non-patient care (e.g., non-­
and learning. According to the SEIPS model, med- clinical conversation). Other studies of medical
ical residents perform a range of tasks (e.g., clini- residents have also shown that significant propor-
cal tasks, learning activities) using various tools tion of their time is spent on tasks that are indi-
and technologies; this occurs in a physical and rectly related to patient care [9] and that medical
organizational environment (see Fig.  7.1). The residents are often interrupted while performing
design of the work system, i.e., its individual ele- tasks [10].
ments and their interactions, influences care pro- Residents perform tasks using various tech-
cesses and educational processes, which in turn nologies, in particular health information tech-
produce outcomes for patients (e.g., patient safety) nologies such as EHR (electronic health record)
and for residents (e.g., well-being, learning). and CPOE (computerized provider order entry).
Medical residents perform a range of tasks Those technologies have significant impact on
that have been documented and described in mul- tasks performed by residents, including time
tiple studies. For instance, Carayon et  al. [8] spent on various tasks and the sequence or flow

Fig. 7.1  SEIPS model applied to medical residents

7  Human Factors and Ergonomics in Health Care and Patient Safety from the Perspective of Medical… 83

of tasks. For instance, after the implementation of who spent 6 h or less per week [14]. The negative
EHR technology in intensive care units, residents impact of the EHR on resident well-being is in
spent significantly more time on clinical docu- part due to the increased clerical (tasks) and doc-
mentation and review: from 18% to 31%, respec- umentation (organization) burden. The SEIPS
tively, before and after EHR implementation model can be used to understand how work sys-
[11]. They also performed a higher frequency of tem factors interact and influence resident out-
activities per hour after EHR implementation: comes such as burnout and learning).
from 117 to 154 activities per hour. This may We adapted a scenario from the AHRQ
reflect increased intensification of work around (Agency for Healthcare Research and Quality)
the use of EHR technology. WebM&M website (https://psnet.ahrq.gov/) to
Eden et al. [12] described several work system demonstrate how work system elements can
factors in graduate medical education that inter- interact and influence patient care.
act and influence residents’ educational process A 70-year-old healthy man (person) went to a rou-
and resident learning; these work system interac- tine follow-up appointment (task) with his primary
tions impact the extent to which the resident care doctor (person). His doctor (person) was a
workforce is able to provide high-quality, patient-­ third-year internal medicine resident in his final
month of training and would soon leave the institu-
centered, and affordable health care. For instance, tion to begin his fellowship. After a discussion
the payment structures (organization), availabil- with the patient, the resident decided to screen him
ity of accredited residency positions (environ- for prostate cancer with the prostate-specific anti-
ment), as well as lifestyle and demographic gen (PSA) test (person and task). In the past, the
patient’s PSA tests had always been normal. This
factors (person) affect the residency pipeline and time, the patient’s PSA test returned and was ele-
the number of physicians in specialty and sub-­ vated at a level where cancer is almost certain
specialty fields. Other work system factors, such (83  ng/ml). However, the resident had completed
as telehealth (technology) and an increased pres- his training before receiving an electronic alert
(technology) about the patient’s PSA test. The
ence of physician assistants (organization) are electronic alert remained unread (technology, task,
changing the roles, responsibilities, and work organization) as there was no system in place that
demands of physicians. The graduate medical supported smooth handoffs to oncoming residents
education work system should be designed so (organization, task, person). Several months later,
the patient (person) presented with low back pain.
that the educational processes produce physi- His new physician, another internal medicine resi-
cians that can support the health needs and goals dent (person), ordered imaging tests (task) that
of populations around the world. confirmed metastatic prostate cancer. While the
A recent report by the National Academies of new resident (person) reviewed the patient’s chart
(task and technology), he uncovered the missed
Sciences, Engineering, and Medicine demon- follow-up for the patient’s elevated PSA.
strates the influence of work system factors on
resident well-being. Forty-five to sixty percent of This scenario includes several interacting
medical residents’ experience symptoms of burn- work system elements (e.g., technology and
out, which is characterized by high emotional organization) that resulted in a patient’s delayed
exhaustion, high depersonalization, and a low diagnosis of prostate cancer.
sense of accomplishment from work [13]. In par-
ticular, the electronic health record (technology)
is recognized as a source of burnout among phy- 7.3  inkage of Work System
L
sicians. For instance, in a study of residents and to Patient Safety
teaching physicians, 37% reported at least 1 and Medical Resident
symptom of burnout with 75% associating burn- Well-Being
out with the use of the EHR. Additionally, physi-
cians who used the EHR after work for more than One of the primary drivers of workplace reform
6 h per week were 3 times more likely to report as it relates to resident well-being and health is
symptoms of burnout compared to physicians through the institution of duty hour limitations.
84 P. Carayon et al.

This reform is largely attributed to the death of rower window and leading to increased stress
Libby Zion, an 18-year-old woman who was [25]. Despite results of the FIRST and iCOM-
under the care of residents in a hospital emer- PARE trials, significant data exist to show that
gency department in New York City in 1984 [15]. extended shifts in the hospital setting can have
Publicity from this case spurred conversations adverse effects on technical and cognitive perfor-
about fatigue and patient safety issues connected mance and lead to impairment outside the work-
to unrestricted hours worked by residents, and place [26–28].
many countries began to impose work hour limi- Work hour limitations in the EU are generally
tations in the 1990s as a result. The European more restrictive than in the United States yet have
Working Time Directive became law in 1998 and led to similarly controversial results. A system-
included limiting physicians working hours to atic review by Rodriguez-Jareño and colleagues
48 h per week and limiting hours for physicians [23] found that long working hours, defined by
in training [16]. Training hours in the United the European Working Time Directive as more
States limited work hours first in 2003 [17], then than 48  h per week, to be associated with an
further in 2011 to a cap of 80 h per week, with the increased incidence of physician needle-stick
aim of improving both patient safety and trainee injuries and motor vehicle accidents. Additionally,
safety [18]. a study by Zahrai et al. [29] found a significant
Measuring the impact of duty hour restrictions relationship between resident hours spent in the
has been controversial. A systematic review in hospital and poor general health and physical
2015 on work hour restrictions found inconsis- function. However, another study found no
tent results, often with studies in direct contradic- improvements in resident self-reported physical
tion with expectations regarding patient safety health by reducing working hours [30].
and resident well-being [19]. Since then two Despite these controversies, efforts should be
large randomized controlled trials have evaluated made to mitigate fatigue and burnout. Burnout
outcomes more extensively, randomizing trainees has been demonstrated to increase cognitive fail-
to restrictive conditions under the 2011 limits vs ures and difficulties with attention [31]. A sys-
more flexible schedules. The FIRST trial ran- tematic review demonstrated a strong connection
domized 118 surgical programs and first pub- between poor well-being and negative patient
lished results in 2015. This was followed by the safety outcomes such as medical errors. This was
iCOMPARE trial, which randomized 63 internal particularly closely linked with depression, anxi-
medicine residency programs. In both studies, ety, poor quality of life, and stress, along with
primary outcomes included no difference in moderate to high levels of burnout [32]. Growing
patient safety events between groups [20, 21] and data on the impact of burnout on both clinical
no significant difference in educational outcomes outcomes and physician safety has led to repeated
between groups [22]. Residents in the iCOM- calls for greater emphasis on addressing this
PARE trial were more satisfied with their educa- issue [33]. This is critical as it relates to training
tional experience in the work hour restricted arm environments for residents along with the broader
of the study though this effect was not seen in the systems in which health care professionals work;
FIRST trial, while program directors were more it is becoming more apparent that fatigue and
satisfied in the flexible schedule study arm. burnout is a significant safety issue for both
The exact degree of duty hour restriction nec- patients and physicians, including physicians-in-­
essary to impact patient safety remains contro- training. Outside of duty hours, several other
versial [23]. Critics of studies showing minimal work system factors can contribute to poor resi-
impact argue that work hour restrictions are dent well-being, fatigue, and burnout including
inconsistently applied or may not be carefully training, work schedule flexibility, autonomy,
implemented [24]. For example, limiting time at clinical experience, and supervisor behavior [34,
work on duty may just shift to more work at home 35]. As there are multiple, sometimes conflicting
when off duty, or compressing work to a nar- goals, regulations on working hours as well as
7  Human Factors and Ergonomics in Health Care and Patient Safety from the Perspective of Medical… 85

other work system factors (e.g., flexibility of dents reported a greater decrease in available
schedules, technology design, training environ- opportunities for bedside learning and teaching
ment) should be carefully considered in order to than surgical residents. The authors of the study
mitigate negative effects on residents and patient noted that duty hours reform may lead to teach-
safety. ing hospitals caring for the same patient volume
with fewer resident physician-hours; therefore,
intensifying the work of residents. Thus, there is
7.4 Challenges and Trade-Offs a need to optimize and improve the resident
in Improving Residents’ work system to consider all outcomes, including
Work System continuity of patient care and educational
opportunities.
Medical residents work and learn in various care
settings and in interaction with other clinicians.
The challenge is how to optimize the work sys- 7.5 Role of Residents
tem of medical residents, as well as the work sys- in Improving Their Work
tems of others that are involved in patient care. In System
a previous section, we discussed the challenge of
designing safe and healthy work schedules for There is a long tradition in the HFE literature and
medical residents. Some interventions aimed at practice of involving “workers” in work system
reducing work hours of medical residents have redesign; this is known as participatory ergonom-
unfortunately had negative impact on the attend- ics [38]. In participatory ergonomics projects, the
ing physicians who supervise them: work gets “workers” participate in providing input and
passed on from medical residents to attending ideas about how to improve tasks, technologies,
physicians who are then experiencing overload environments, organizations, and processes.
and stress. Therefore, any intervention aimed at Sometimes workers are actively engaged in mak-
improving the work system of medical residents ing decisions about how to redesign the work
needs to prevent or mitigate negative conse- system. Participatory ergonomics projects vary
quences for other health care professionals with regard to content (e.g., improving the design
involved in patient care. of EHR technology), decision making (e.g., pro-
Improving residents’ work system can be viding input or making decisions on process
challenging as it may lead to improvement in improvement), and stage (e.g., initial analysis of
some outcomes, but deterioration in other out- work system or implementation of redesign)
comes. Myers et al. [36] assessed internal medi- [39]. In a project aimed at enhancing family
cine and general surgical residents’ attitudes engagement in bedside rounding in a pediatric
about the effects of the Accreditation Council for hospital, researchers implemented a participatory
General Medical Education duty hours regula- ergonomics process in which residents along
tions effective July 1, 2003 [37]. They surveyed with attending physicians, nurses, and parent
111 internal medicine residents and 48 general proposed and helped to implement a bundle of
surgical residents from six geographically interventions [40]. The interventions consisted of
diverse programs in the United States. The sam- a checklist of best practices for engaging families
ple was limited to residents who had experienced during bedside rounding (e.g., introducing health
residency before and after implementation of the care team members) and training of residents in
duty hours regulations. The survey included the new rounding process. Specific elements of
questions on residents’ opinions of [1] quality of the checklist (e.g., asking the family for ques-
patient care and safety and [2] residency educa- tions, reading back orders) were related to
tion. Both medical and surgical residents improvement in perceived quality and safety of
reported that the quality of care decreased with care by parents [41]. Involving residents in this
continuity of care decreasing a lot. Medical resi- work system and process redesign was critical to
86 P. Carayon et al.

the successful implementation of the interven- paragraph, we lay out a model for a resident
tions as key stakeholders. In addition to involving safety council drawing on experiences published
residents in specific improvement projects, health by several institutions in the United States and
care organizations have created dedicated struc- Canada [42, 46]. Similar councils have since
tures to involve residents more systematically, demonstrated measurable improvements in
such as involvement of residents in safety/quality improvements in patient safety goals [47, 48].
councils [42]. The following should be considered when
The Institute of Medicine report “Resident designing and implementing a resident safety
Duty Hours: Enhancing Sleep, Supervision, council:
and Safety” [43] spurred a significant change in
resident work structure. It also prompted greater • The council should be resident led.
emphasis on both training and direct resident • Appoint a resident chair who works directly
involvement in quality improvement and patient along system administrators and other hospi-
safety initiatives. Out of this movement, the tal groups to direct quality improvement
Accreditation Council for Graduate Medical projects.
Education in the United States (ACGME) • Relevant subcommittees, for example,
drafted its Clinical Learning Environment Quality, Safety, Research, Education, each
Review (CLER) guidelines in 2014 [44]. chaired by council members can further direct
Included in the guidelines are requirements that the focus of the group.
training programs integrate quality improve- • Agendas and meeting topics are both chosen
ment and patient safety training into resident by and presented by residents to this helps
curricula and that residents should have direct assure that meetings remain interactive and
involvement in organizational quality improve- productive, rather than becoming a series of
ment projects. Hospitals and health systems lectures.
have taken a variety of strategies to fulfill this • The safety council should remain voluntary
requirement while also integrating residents though with an effort to establish representa-
into quality improvement initiatives and work tion from all training programs at an
system redesigns. institution.
A systematic review in 2010 identified com- • Encourage a multidisciplinary presence at
ponents for a resident quality curriculum, which council meetings. Graduate medical education
should include concepts of continuous quality staff, hospital administrators, representatives
improvement, root cause analysis, and systems from organizational QI and patient safety
thinking [45]. Implementation of quality curri- departments, and patient–family representa-
cula was well accepted and effective in improv- tives should all be involved in meetings.
ing knowledge. Further, 32% of studied curricula • The safety council should serve as a tool to
(13/41) resulted in local changes in care delivery draw residents directly onto institutional QI
and 17% (13/41) significantly improved target committees, such as Event Evaluation Teams,
processes of care, indicating that direct training Root Cause Analysis, Medical Records com-
itself of trainees can improve the quality environ- mittees, and Interdisciplinary Model of Care
ment of an organization. Committees.
Several organizations have heeded the call for
resident involvement in improving their work Implementing a robust quality improvement
systems by establishing quality councils and and safety curriculum supported by a resident-led
safety officer positions for residents and other council can empower residents to implement
trainees [4]. This is a critical component to boost- large-scale quality work, to engage their peers,
ing resident involvement in safety and quality and help foster growth of the next generation of
improvement their institutions. In the following leaders in patient safety.
7  Human Factors and Ergonomics in Health Care and Patient Safety from the Perspective of Medical… 87

7.6 Conclusion 6. Carayon P, Hundt AS, Karsh B-T, Gurses AP,

Alvarado CJ, Smith M, et  al. Work system design
for patient safety: the SEIPS model. Qual Saf Health
In many health care organizations, especially Care. 2006;15(Suppl I):i50–8.
academic medical centers, residents are the pri- 7. Carayon P, Wetterneck TB, Rivera-Rodriguez AJ,
mary clinicians providing patient care. Hundt AS, Hoonakker P, Holden R, et  al. Human
factors systems approach to healthcare quality and
Recognizing the unique needs of medical resi- patient safety. Appl Ergon. 2014;45(1):14–25.
dents both in their role of delivering safe and 8. Carayon P, Weinger MB, Brown R, Cartmill R,
effective care and also in meeting their educa- Slagle J, Van Roy KS, et al. How do residents spend
tional objectives requires a robust approach to their time in the intensive care unit? Am J Med Sci.
2015;350(5):403–8.
understand the work systems in which residents 9. Hollingsworth JC, Chisholm CD, Giles BK, Cordell
operate. Human factors and ergonomics princi- WH, Nelson DR.  How do physicians and nurses
ples, and specifically the Systems Engineering spend their time in the emergency department? Ann
Initiative for Patient Safety (SEIPS) model, can Emerg Med. 1998;31(1):87–91.
10. Gabow PAMD, Karkhanis AMS, Knight ARN,

inform decisions when working to evaluate and Dixon PP, Eisert SP, Albert RKMD. Observations of
improve resident work systems. This is particu- residents’ work activities for 24 consecutive hours:
larly important when addressing patient safety Implications for workflow redesign. Acad Med.
and resident well-being. As health care becomes 2006;81(8):766–75.
11. Carayon P, Wetterneck TB, Alyousef B, Brown RL,
increasingly interconnected and reliant on multi- Cartmill RS, McGuire K, et al. Impact of electronic
disciplinary teams, it is important to consider health record technology on the work and workflow
unanticipated consequences of changes in work of physicians in the intensive care unit. Int J Med Inf.
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12. Eden J, Berwick D, Wilensky G.  Graduate medical
cesses and outcomes for residents, but also for all education that meets the nation’s health needs. ERIC;
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13. National Academies of Sciences E, and Medicine.
Acknowledgments This chapter was supported by the Taking action against clinician burnout: a systems
Clinical and Translational Science Award (CTSA) pro- approach to professional well-being. Washington,
gram, through the NIH National Center for Advancing DC: National Academies Press; 2020.
Translational Sciences (NCATS), Grant Number: 14. Robertson SL, Robinson MD, Reid A.  Electronic

1UL1TR002373. The content is solely the responsibility health record effects on work-life balance and burnout
of the authors and does not necessarily represent the offi- within the I(3) population collaborative. J Grad Med
cial views of the NIH. Educ. 2017;9(4):479–84.
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the Libby Zion case on graduate medical educa-
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 Part II
Background