Patient Harm
Patient safety has risen up the agenda of clinical, managerial and political leaders in healthcare over recent years. In England the recent “Safety First” report has highlighted that despite progress including growing commitment of leaders, strengthening governance in NHS Trusts, and development of NPSA reporting systems, all the evidence is that patients still continue to be harmed on a frequent basis.
We have become aware of a huge issue but seem unable to really address it. We can “know” what needs to be done and yet the problem appears to persist. It appears to be a “wicked problem, which resists definition and solution. To address it might require much behaviour that runs counter to intuition and political realities.
The issue of patient harm is analogous to that of manufacturing product quality during the pre-total quality movement of the 1970s and onward. Just as quality needed to be understood as a systems issue, the same is true of patient harm. It has elements at the level of the individual, the group, the organisation and the larger political and social context in which it is embedded. The transformation in manufacturing quality came from a whole system approach that also improved productivity, staff motivation and customer service.
The same whole system transformation is needed in healthcare systems if patient safety is really to be addressed. This will require courageous leadership from all of us within the healthcare system – placing compassionate and safe care back at the heart of healthcare.
Tricordant hosted a 1-day conference, Patient Harm: strategies for Solving a wicked problem, on 8th May 2007. These pages contain a report of the conference and copies of the presentations and papers referenced.
