Rethinking Patient Safety by Suzette Woodward

By Suzette Woodward

The overwhelming majority of healthcare is supplied appropriately and successfully. although, similar to any high-risk undefined, issues can and do get it wrong. there's a international of recommendation approximately the best way to maintain humans secure yet this gives you little by way of replaced perform.

Written by means of a number one professional within the box with over 20 years of expertise, Rethinking sufferer Safety presents readers with a severe mirrored image upon what it may possibly take to slim the implementation hole among the facts base approximately sufferer protection and genuine perform. This ebook presents vital examples for the numerous execs who paintings in sufferer safeguard yet are suffering to slender the distance and make a distinction of their present situation.

It offers insights on sensible activities that may be instantly carried out to enhance the security of sufferer care in healthcare and offers readers with a unique state of mind by way of altering habit and practices in addition to methods and platforms.

Suzette Woodward stocks classes from the technological know-how of implementation, campaigning and social stream tools and gives the reader the tale of a discovery. Her workforce has explored an strategy which can profoundly have an effect on the protection tradition in healthcare; a technique to aid humans check with one another and their sufferers and to pay attention via facilitated defense conversations. this is often their story.

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With respect to patient safety, incidents happen across the system as a result of a variety of factors and pressures that increase the risk at certain points. In fact, rather than incidents being a chance occurrence, they tend to involve a migration from safe care to unsafe care over time (Leveson 2012, Vincent and Amalberti 2016). Avoidable patient harm is in part attributed to a diverse spectrum of error-producing conditions across the system such as ◾◾ Human factors: Variation in training, individual experience, fatigue, boredom, depression and burnout ◾◾ Diversity of patients: Variation in age, severity of illness and comorbidities ◾◾ Working hours: Types of shift patterns and length of working hours ◾◾ Complicated technologies: Equipment, tasks and procedures ◾◾ Drugs: Calculations, drug names that look and sound alike, prescriptions, computerised prescribing and alert systems ◾◾ Design: Poor packaging, poor labelling and design of equipment ◾◾ Length of stay: Prolonged or multiple transfers ◾◾ Poor communication, handover, transitions and information A safer system is one that is able to adapt and able to help the people who work within it adapt to their environment or to changes in their environment (Rasmussen 1990).

Instead of humans being seen as a liability, in Safety II the systems are considered unsafe and the people create safety; humans are seen as a necessary component of system flexibility and resilience. Hollnagel describes Safety I as a condition where as little as possible goes wrong and Safety II as a condition where as much as possible goes right. The pursuit is one of building a system where everything goes right. It is also the ability to succeed under unexpected conditions so that the number of intended actions and acceptable outcomes is as high as possible.

A typical night was not that much different to a day and included multiple interruptions: telephone calls, visiting families, visiting doctors and questions from the team. This particular set of nights was very busy, but again this was not unusual. With only a few hours’ sleep, I was exhausted; despite many years of practice, I was particularly bad at sleeping on night duty. A Culture of Learning ◾ 31 A number of our tasks had become very routine, and one of these was the drug rounds. These usually took over an hour as each child had multiple medications via multiple routes to be calculated and administered.

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