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The measurement and monitoring of safety

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Published: April 2013
Author(s):

Charles Vincent; Susan Burnett; Jane Carthey

ISBN: 978-1-906461-44-7

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In the last decade in the UK there has been a huge volume of data collected on medical error and harm to patients, as well as a number of tragic cases of healthcare failure and a growing volume of government reports on the need to make care safer. Despite this, we still don’t know how safe care really is. Assessing safety by what has happened in the past does not give us the whole picture nor does it tell us how safe care is now or will be in the future.

In The measurement and monitoring of safety, Charles Vincent and colleagues from Imperial College London propose a new framework to help find the elusive answer to the question – how safe is care today?

We hope this report will trigger debate and discussion that will lead to a new way of thinking about patient safety, and shape the safety improvement work of the future.

Five dimensions: a proposed framework

This framework highlights the following five dimensions, which the authors believe should be included in any safety and monitoring approach in order to give a comprehensive and rounded picture of an organisation’s safety:

  • Past harm: this encompasses both psychological and physical measures.
  • Reliability: this is defined as ‘failure free operation over time’ and applies to measures of behaviour, processes and systems.
  • Sensitivity to operations: the information and capacity to monitor safety on an hourly or daily basis.
  • Anticipation and preparedness: the ability to anticipate, and be prepared for, problems.
  • Integration and learning: the ability to respond to, and improve from, safety information.

This framework provides a starting point for discussions about what ‘safety’ means and how it can be actively managed. A diagram of the framework is available. There is also a diagram of the framework including suggestions of measures that might be used for each dimension.

Share your thoughts about the report and the framework in the comments section below.

Additional patient safety resources

If you’re interested in patient safety then take a look at our dedicated Patient safety resource centre for hundreds of practical tools, materials and downloads.





 
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Comments
I must say this is a pretty comprehensive work done by professionals. Very well done. What I see as a "major gap" in all initiatives related to patient safety and quality improvement is that we have not been able to institutionalize it at industry level, like done for aviation. I understand we have very different dynamics and need to develop standards pertaining to our industry. There are many forums and institutions working towards this goal like ISQua, JC, Planetree etc. There is something "missing" in this link, something that can really "TRANSFORM" the "way we work".
I applaud your efforts to measure safety, but too many people are harmed by the side effects of drugs. eg, Adverse drug reactions hospitalise a million of us every year. We need to give patients drug free alternative treatments, such as NICE recommended complementary therapy. However, so little of this is commissioned that the waiting time for the Mindfulness Based Cognitive Therapy (MBCT) course is 20 years in Sussex. My company SECTCo has bid unsuccessfully to provide this, see www.reginaldkapp.org section 9.56. Please contact me if interested on johnkapp@btinternet.com
The complexity of this is captured really well adn the focus is right. Safety is a 'wicked problem' which requires multiple coordinated interventions. The focus of a single system of centralised (live and retrospective) data releasing potential for all levels to act and prevent is key.

Often there are operation sensitive data which can act as early warning indicators i.e. student feedback but this does not get the right prominance with all of the other data collected.

Really interested in what this report would mean in respect of how we train/educate for safety i.e. should this be mandatory for some staff groups i.e. theatre staff/operation sensitive areas. Simulation education and human factors training would be key to supporting this.
The aviation industry has CHIRP, this is a confidential reporting program for human incidents. The team analyse the contributions and regularly feedback on changes to process, systems etc that are required to learn from the incidents. Contributors (people making reports) are protected completely - their identity is not stored so that it is impossible to trace the source of the report. The history can be found here: https://www.chirp.co.uk/downloads/CHIRP%205pp.pdf
It seems self evident to me that Health Care could benefit hugely from such a scheme.
It may be that we have one?
I would be very interested in other's comments.
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