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Patient Safety



Patient Safety

In 1990, researchers in the health care system found that despite the achievements of modern medicine illnesses’ treatment, hospitals did not provide a satisfactory safe environment for healing. Hospitals were found to be not safe enough for patients to avoid injuries. Practitioners in the health care system have responded to this statement by increasing interest in patient safety. Patient safety has been defined as a complete discipline embracing vast storage of knowledge with the potential to become a major branch in the health care system. This paper begins by introducing essential aspects in the history of patient safety; patient safety is then defined and described. The paper concludes by suggesting ways to improve patient safety in the medical setting.

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Intellectual History

Scholars in the health care system proposed the main suppositions after intensive patient safety research. The main task was to understand why health care professionals make errors that cause adverse events in patients. The causes under question included legal issues, engineering design, and individual incompetence. Traditional thinking assumed that adequately trained practitioners are not prone to making errors. The thinking associated errors with incompetence and prescribed punishment as an effective measure for practitioners to reduce professional errors.

As a result, this kind of thinking made the practitioners conceal their mistakes and denied patients access to relevant information. Thus, the low reporting of errors complicated the process of learning from mistakes. The reversal of this thinking began in 1990 when preventable medical injuries were found to increase at an alarming rate (Aspden, Corrigan, Wolcott, & Erickson, 2004). It was also found that errors made by practitioners in the process of interacting with patients were caused by upstream defects in system design, management, organization, training, and equipment. The application of punishment as a solution to errors made little sense as errors continued to take place until the organizations resolved the underlying upstream causes.

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System Thinking

Thought leaders argued that redesigning processes and systems using human factors could reduce errors (Aspden et al., 2004). Mistakes could be reduced through design features such as simplification, standardization, and the use of constraints. Another milestone in the process of patient safety and care improvement occurred when practitioners applied the concepts of engineering design to health care. Part of the system changes was related to technology, such as the computerization of physician medication prescribing. Another part was related to people and organizations, such as providing training to nurses and doctors to improve teamwork. Thus, people changed the perception of health care delivery to system thinking and began to perceive health care delivery as an open system consisting of regulators, insurance administrators, payers, technology suppliers, and policymakers.

Transparency and Learning

The idea that adverse events had the potential to spread information found its application in health care. It was found that sharing information about medical errors was important for effective patient safety outcomes. The sharing of error-related information was found to yield better lessons for industry-wide implementation. It was also identified that knowledge of systems required an understanding of how errors were made.

Culture and Professionalism

The health care system began encouraging executive leaders, clinicians, middle managers, and governing boards to build high-reliability organizations. This called for a cultural change in health care, which implied withholding from blaming the professionals for mistakes, encouragement to learn by disclosing all the information about errors, offering full disclosure of facts to injured patients, and supporting clinicians involved in risky duties (Kalra, 2011).

The change in thinking promoted approaches that were anchored in the ethical underpinning of the health care system. The increased agitation for safety became an essential part of the medical profession leading to the coining of the maxim ‘do no harm’ (Kalra, 2011). System-wide transparency was incorporated in the fundamental professional standards that required full disclosure of relevant facts to the patient.

Accountability for Delivering Safe Care

The early traditions in the medical field kept in deep secret the knowledge and skills of medical practices. At that time, medical methods were rooted in dubious foundations and were frequently harmful. However, the healthcare system faced the challenge of securing society’s trust. The main task was to eliminate charlatans. After the development of the concept of negligence and its incorporation in medicine, litigation deterred adverse behavior and instilled individual accountability for actions associated with adverse outcomes.

As the effectiveness of treatment increased, the medical field embarked on establishing methods for accountability, and it became more credible. The scientific method was instrumental in this process. A three-phase approach was involved in establishing the safety of new therapies. The first phase involved assessing the safety and efficacy of therapies through clinical trials. The second phase involved ascertaining efficacy using clinical trials. The third phase involved conducting trials to compare with other interventions. The use of randomized clinical trials as the basis of the scientific method was important in the process that process aimed at transforming the medical industry into clinical research-driven practice. The objective was achieved as a society recognized a health care practitioner to be a reputable profession (Byers & White, 2004).

The expansion of medical sciences also revolutionized the standards of medical education. The development of specialties generated the need to legitimize and codify expertise through certification. Medical surgeries became safer and more effective, and the focus of medical care delivery was put on hospitals. Professional groups were formed and began the certification of health care facilities. The professional groups performed public protection and oversight roles.

Rethinking Risk

Medical practitioners began developing new ways to address physician-patient relationships. Risk management and quality improvement were developed as specific disciplines in the health care system. Both of them emphasized research-based health services delivery. These developments set the pace for the adaptation of developments in other disciplines, such as engineering in medicine.

Team Work and Dyadic Relationships

For a long time, clinicians and other workers in the health care system had a dysfunctional relationship. Health care practitioners realized that emphasis on team functioning could help solve this problem. Therefore, teamwork training was introduced as an important component of patient safety. A new vision of patient safety included patient-centered care with a focus on interdisciplinary teams (Byers & White, 2004).

Definition of Patient Safety

According to the Institute of Medicine (IOM), patient safety is treatment-free from accidental injury. In 1998, IOM revised the definition of patient safety and characterized it as the level, to which health care services increase the occurrence of desired health outcomes and consistency with professional knowledge (Matlow & Laxer, 2007).

The IOM identified three problems facing patient safety. They include misuse, overuse, and underuse. The institute defined misuse as complications in treatment that are preventable. Misuse became a reference point for the conceptualization of patient safety as a quality component. The National Patient Safety Foundation defined patient safety as the prevention and avoidance of injuries and adverse outcomes emanating from the process of care (Matlow & Laxer, 2007).

To summarize all these definitions, patient safety can be defined as a discipline in the health care system that utilizes safety science methods to create a trustworthy system of health care delivery. As an attribute of the health care system, patient safety minimizes the impact of adverse events and expedites the recovery from adverse events when they occur.

Reasons for Patient Safety

Patient safety was the response to the realization that adverse medical events are common and preventable. Patient safety aims at minimizing adverse events and eliminating preventable harm in delivering health care.

The Nature of Patient Safety

Patient safety has been incorporated as a new discipline in the health care system. The curricula in this field are structured in recognition of this new discipline. Integrally, patient safety aims at increasing the quality of health care.

Patient safety has its core foundation in system design as it is an attribute of the health care system. Patient safety aims to achieve high reliability even in conditions of risk. The discipline has a vast application in therapeutic intervention. The medicinal risks may be rather daring such as in cases of cardiac transplantation surgery.

Patient safety requires the re-designing of systems to increase the reliability of risky interventions. It applies two tenets of the complexity theory. The first tenet states that highly complex systems increase the propensity for chaos. The second tenet states that open, interacting systems increase the likelihood of unpredictable events (Sanchez, 2012). Better therapeutic designs are more resilient in the event of predictable and unpredictable failure and thus increase the chances of prevention and rescue. Safety systems encompass the design of the environment, procedures, training, materials, and culture of the people involved in health care delivery.

Patient care has a highly personal nature. The provision of care requires health care workers to cross physical and psychological boundaries. The health care system developed codes of ethics to guide the provision of health care while protecting patient integrity. Patient safety allows restrictions such as physical privacy, confidentiality, among others, to avoid dishonesty about the patient.

Another feature of patient safety is the natural progression of the illness. The instigation of illness care is an indication that the health condition of the patient is not right. A health care practitioner’s failure to provide the appropriate intervention harms the patient. For example, a missed diagnosis may cause adverse effects including death. The patient safety discipline prescribes stern disciplinary measures for health care workers responsible for causing harm due to the omission of actions or due to inappropriate actions.

Patient safety depends on open learning. In part, continuous learning depends on errors as the source of understanding. Patient safety requires a culture of openness and treatment of those involved in adverse events as partners in learning. In this respect, patient safety embraces reporting of adverse events, disseminating the lessons learned, desisting from allocating unfair blame, and continuous learning. Patient safety seeks to understand errors that lie beyond the control of an individual.

In addition, patient safety proposes abandoning the traditions of the guild, which shielded practitioners from accountability. It also rejects the defensive nature of ancient risk management approaches, which taught physicians to deny any responsibility and defend justified and unjustified malpractice claims. Patient safety calls for personal and organizational accountability but emphasizes the importance of learning from mistakes. It requires maintenance of integrity in physician-patient interaction, especially with patients who have experienced avoidable adverse events (Sanchez, 2012).

Truthfulness is an important virtue in patient safety. Though errors and adverse events may happen, the health care system is accountable to apply safety sciences optimally. Patient safety prevents and minimizes adverse events by directing attention to interactions and systems and facilitating learning from past occurrences. All the stakeholders act to minimize and prevent the impact of adverse events that cannot be avoided. It is achieved by seeking well-informed, motivated, and conscious personnel and creating a properly designed system. Patient safety also seeks to repair damages honestly and respectably when they occur.

Where Patient Safety Occurs

Patient safety occurs in the microsystem. It occurs in the environment of patient care, which may be the emergency department, hospital ward, operation room, and related areas where ‘sharp end’ services are provided. The environment of patient safety is the microsystem where patients interact with caregivers, where patients may be harmed, and where the failure of patient safety may occur. Patient safety breaches may occur in ‘blunt end’ components. The events include properties of interaction in the entire system. Therefore, patient safety mostly concerns systems. Though patient safety often manifests at the point of physician-patient interaction, the success or failure of the entire system determines safety coverage.

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Patient Safety Practitioners

Patient safety practitioners include all members involved in health care service delivery. They include pharmacists, doctors, nurses, equipment and plant managers, information management experts, clinicians, and others who perform health care duties. The unique characteristics of this person should have included patient safety vigilance and the ability to recognize adverse events, among others. They should also have the ability to pre-empt and mitigate errors to rescue patients from adverse impacts. In addition, they should be excellent team players to substitute during shift work.

How to Achieve Patient Safety

The following mechanisms help achieve patient safety.

High-Reliability Design

High-reliability design is the primary mechanism that can be used to achieve patient safety. It includes various components. The unit of patient safety requires the integration of all components of the health care delivery systems into a reliable system under complex conditions. The complexity theory demonstrates the resilience of high-reliability designs even in the occurrence of unpredictable events (Sanchez, 2012). Lean processes are another design feature that helps system engineers. These levels of reliability use better and simplified processes.

The model of accidental causation presents a multilayered system, which requires the alignment of failures within each layer for an error to occur. The building blocks of the system include the institution, its organization, the technology used, and the professional team and individuals included. The health care safety system design is in its early stage of development. Patient safety designs are divided into two categories: designs for types of routine care and designs for unique situations. Designs for routine care can be managed with protocols, with a little provision for deviation. Designs for unique situations require on-the-spot innovation and substantial deviation from protocol.

Safety Sciences

Safety Sciences refer to the methods of acquisition of knowledge of safety and its application to create high-reliability designs. The main aim is to design systems that ensure proper execution. The ideal design helps the operator perform functions properly. Much of the development aims at creating defenses that prevent unsafe actions from resulting in harm (Aspden et al., 2004). For the developments made so far, a practitioner needs to breach several of them to cause harm.

Another method of achieving patient safety is the acquisition of objective knowledge. Patient safety requires the use of methods that are appropriate for the purpose. The methods are drawn from different disciplines. For example, the methods for understanding human errors are drawn from human psychology; system quality improvement is drawn from engineering and organizational behavior - from social sciences. The methods drawn from health service research include repeat tests and controlled experiments. The different disciplines should be used to understand the various causes of adverse events. For example, social sciences should be used to understand failure in human performance. Engineering should be used to understand a machine failure.

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Methods of Causing Change

Patient safety aims at engaging methods to cause improvements that exceed knowledge transmission and skills acquisition. It is based on techniques of quality improvement. Continuous quality improvement should focus on health care delivery systems. The methods should improve services where actual practices do not match with acknowledged standards. Then, quality standards should be monitored for the maintenance of new standards. Adverse events should be analyzed and the system of care re-designed appropriately.


Patient safety is important in responding to avoidable adverse events. Definitions and descriptions of patient safety are provided as a guide to organizations. The primary focus of actions is identified as the microsystem. The essential mechanisms of ensuring patient safety are the use of high-reliability design and the application of safety sciences to cause improvements. The descriptions of the key attribute of practitioners are also provided. The system of patient safety is described as an interaction of patients who receive care, the providers of care, the system of therapeutic action, and the elements of the three actors. This description will be crucial in assisting the incorporation of patient safety practices in the health care delivery environment.

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