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How confident are you that the risk management processes in your organisation enable you to predict and manage all the risks your patients are likely to face? If you have doubts, you’re probably not alone, as the findings from our Safer Clinical Systems programme suggest.  

Looking back at my time on the board of a hospital, risk management was generally based on records of past incidents rather than a proactive assessment of risks that could occur in the future. Approaches ranged from a dashboard tallying up data on mortality and individual causes of harm, to overwhelming 100-line tables detailing incidents, risks and action plans.

While there is no doubting the strong commitment of health care services to safety, our Safer Clinical Systems programme suggests that safety is too complex to be adequately controlled through these approaches. The pattern of past incidents can certainly help us understand and improve safety, but is simply not a sufficient predictor of how circumstances will combine to cause the next problem that will arise. We need a more systematic approach to identifying and addressing potential safety hazards.

Since 2008, we have been working with frontline NHS teams and experts from Warwick University to explore what health care can learn from the approach to safety taken in other hazardous industries, such as mining, aviation and nuclear power.

Using techniques adapted from these industries, project teams conducted a systematic analysis to understand hazards that are likely to contribute to harm across whole pathways. This proactive approach is currently rare in standard NHS practice and revealed many ways in which health care can go wrong that are below the radar of incident reporting and risk management processes. For example, one team looking at the shared care pathway for renal patients having a surgical intervention identified 99 different hazards that they were then able to rank and develop strategies to address.

The participating clinical teams identified hazards that were new even to the people who’d worked in an area for some time. Teams reported that this new approach also gave legitimacy to concerns they had known about and been working around for years. For the first time, they had a way to understand and tackle every day risks systematically.

The implications of the evaluation of this programme go beyond risk management. The evaluators paint a sobering broader picture of pervasive poor process design. 

Many of the basic processes patients and health care professionals rely on every day had never been purposefully designed but had simply been learned on the job. Over time, many systems had evolved in a way that often unintentionally prioritised efficiency and task completion over safety. 

The evaluation also shines a light on entrenched problems associated with IT, staffing and other infrastructure issues that get in the way of safe delivery of care and efforts to improve it. There are endless examples of people coming up against ‘systems that were stressful to use, created distractions or interruptions and wasted resources and time’. Finding solutions to these industry-wide barriers to progress will go a long way to helping meet ambitious safety goals.

Patient safety problems exist throughout the NHS, as in all health care systems in the world. Improving safety requires action on all levels. NHS staff are passionate about patient safety and can play an important role in improving it. However, it will rarely be reasonable to delegate complex safety improvement objectives to small frontline teams without the senior commitment and skilled support necessary to enable organisation or wider system redesign. The extent and complexity of the changes needed mean that achieving our safety ambitions requires us to both update our approaches to managing risk and ensure mainstream investment to improve process analysis and design skills.

This blog first appeared on BMJ blogs

Penny is an Assistant Director at the Health Foundation, ww.twitter.com/PennyPereira1

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