A shift in thinking about safety

‘Safer healthcare: strategies for the real world’ is a new book by Charles Vincent (Health Foundation Professorial Fellow and Professor of Psychology at the University of Oxford) and René Amalberti (Professor of Medicine at Haute Autorité de Santé), to be published early next year. We spoke to Charles about the authors’ new vision of patient safety and what this means for keeping care safe in different health settings.

Tell us about your new book and how it came to be written?

The starting point was René Amalberti’s observation in 2013 that the huge technological and organisational changes emerging in health care would have considerable implications for patient safety. I also suggested that care provided in the home and community were an important focus and we planned papers addressing these subjects. We began to speak about the need for a new vision of patient safety and it got to the point that we felt a book was needed to express these ideas in their entirety.

In what way do we need to think differently about safety?

Previous work to improve patient safety has been driven by studies of specific incidents in which people have been harmed by health care. Eliminating these distressing, sometimes tragic, events remains a priority but this ambition does not really capture the challenges before us. While patient safety has brought many advances we believe that we will have to conceptualise the enterprise differently if we are to advance further.

In our new book we argue that we need to see safety through the patient’s eyes, to consider how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast as the management of risk over time. 

Your book is subtitled, ‘strategies for the real world?’ – what does this mean?

Almost all current safety initiatives are either attempts to improve the reliability of clinical processes or wider system improvement initiatives. These are all important and valuable, the only problem is that, for a host of reasons, it is often impossible to provide optimal care. 

Very few safety strategies are aimed at managing risk in the often complex and adverse daily working conditions of health care. The current strategies work well in a reasonably controlled environment but they are in a sense idealistic. We argue in the book that they need to be complemented by strategies that are explicitly aimed at managing risk ‘in the real world’.

How is the safety agenda affected by the current trend to move care out of hospitals?

We have found it difficult to make hospitals safe, even with a highly trained and professional workforce within a relatively strong regulatory framework. More care is now being delivered in patients’ homes and patients and carers are taking on many tasks formerly carried out by professionals. We will shortly be trying to achieve similar standards of safety with a largely untrained workforce (patients and their carers) in settings not designed for health care and with almost no effective oversight or supervision. This may prove challenging. 

That’s why we argue that the health care of the future will require a new vision of patient safety necessarily focused on the patient and their environment more than on professionals and the hospital environment. We need to consider the new risks that will emerge, and the potential burden on patients, family and carers as they take on increasing responsibilities.

How much do we need to vary our approach to safety depending on the setting?

Safety can’t be approached in the same way in all clinical environments. Strategies for managing safety in highly standardised and controlled environments are necessarily different from those in which clinicians must constantly adapt and respond to changing circumstances.

The book outlines an architecture of safety strategies and associated interventions that can be used both to manage safety on a day to day basis and to improve safety over the long term. 

Clinicians, managers and others take action every day to manage risk but curiously this is not generally seen as patient safety. We need to find a vision that brings all the potential ways of managing risk and safety into one broad frame. Optimisation strategies (those that aim to optimise care) improve efficiency and other aspects of quality as much as they improve safety. In contrast risk control, adaptation and recovery strategies are mostly concerned with improving safety. Such strategies are needed at all levels of the health care system, from the front line to the regulatory and governance structures.

Find out more

Safer healthcare: strategies for the real world will be published in early 2016. The Health Foundation is funding free access to the e-book version. Please email Helen Crisp if you would like to receive a copy of the e-book when published and/or would like an invite to the book launch.