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Over the past three decades, the predominant approach to improving safety in health care has involved studying adverse outcomes to identify system vulnerabilities and correct them. While this approach has been useful, it has limitations. A focus only on unfavourable outcomes can limit innovation and adaptability, not to mention undermine worker morale and engagement.
James Reason once characterised the goal of error investigations as ‘draining the swamp, not swatting mosquitoes’. Critical incidents arise from the interplay between active failures (eg. not double-checking for allergies before administering a medication) and latent conditions (eg. workload).
Many hospitals continue to use incident reporting systems (IRSs) as their primary patient safety data source. The information IRSs collect on the frequency of harm to patients [adverse events (AEs)] is generally of poor quality, and some incident types (e.g. diagnostic errors) are under-reported. Other methods of collecting patient safety information using medical record review, such as the Global Trigger Tool (GTT), have been developed. The aim of this study was to undertake a systematic review to empirically quantify the gap between the percentage of AEs detected using the GTT to those that are also detected via IRSs.
SystemsThinking - A New Direction in Healthcare Incident Investigation.
The Managing Clinical Risk in Primary Health Care document is designed as a resource for staff in primary health care services. The document has been developed after consultation with practitioners, managers, risk specialists and with reference to the conceptual framework provided by the Victorian Quality Council.
Dignity of risk is another way of saying you have the right to live the life you choose, even if your choices involve some risk.
This 'Dignity of Risk' research project aims to determine policy and decision-makers perceptions of ‘Dignity of Risk’ as it applies to vulnerable older persons living in residential aged care services.
In this No Harm Done podcast, Dr Cathy Balding and Cathy Jones delve into the clinical risk management depths.
This guide is a resource to help support individual and organisational learning and to drive quality improvement, in response to patient safety incidents. Organisations may also choose to use the guide to support quality assurance processes.
