Resources

In Australian health services, roles that support consumer safety are a mix of trained specialists, people who evolve on the job and those who struggle through the basics with little opportunity for development. In the UK,  the NHS has created a new role of ‘patient safety specialist’, introduced to bring a more structured, professional approach to patient safety. This evaluation article seeks to understand the professionalisation of patient safety, with implications for the further development of patient safety specialists in the UK and other countries. 

Medication errors remain a stubbornly challenging issue in the provision of safe care. Although we often associate inpatient settings with medication issues, this comprehensive review studied the triumvirate of prescribing, dispensing and administration to determine common causal factors of mistakes and inaccuracies, leading to incidents in ambulatory and outpatient settings.

Variation in healthcare quality is an ongoing issue. This study seeks to understand how differences in hospital practices and policies can lead to disparities in consumer outcomes and overall care quality. The authors compared process and outcome measures to detect variation and characteristics of hospitals with lower variation.

Outpatient safety receives a different level of discussion and focus than inpatient safety. We may not consider that outpatients can experience harm in the same way that inpatients can, which could reduce the focus on collecting accurate outpatient incident data. But even outpatient care can cause life-threatening harm, as this study shows.

We frequently discuss the importance of a ‘safety culture’ in human services – but what are the key ingredients? This scoping review synthesises evidence from multiple studies to identify key factors contributing to patient safety culture. Although the review focused on hospitals, the findings are relevant for all human service leaders seeking to build or strengthen their culture of safety.

Clinical Guidelines are developed to standardise practice and provide a solid evidence base for care. They are essential components of clinical governance to support safe and effective care and serve as valuable tools for training.  

As this study reveals, guidelines can also be a source of confusion and misapplication. Ambiguities in guidelines can result in varying interpretations among healthcare providers, contributing to inconsistent care and potential patient harm. 

The inter-dependency of clinician wellbeing and patient safety is well accepted. Staff burnout is a widespread problem and patient safety improvement appears to have stalled. This survey of 2187 physicians and 6643 nurses practising in 64 hospitals in six European countries investigated the well-being of physicians and nurses in hospital practice in Europe, and identified interventions that hold promise for reducing adverse clinician outcomes and improving patient safety.

Trying to improve care in human services can be overwhelming. We start out with great aspirations to fix a care quality issue. But as we get closer to the problem it appears to loom ever larger, and we wonder what we’ve got ourselves into. Most care quality issues are entrenched and multifaceted and can’t be solved by a single solution or big-bang change. Often our initial enthusiasm wanes and we default to revising the procedure and running training because everything else seems too hard. Essentially, we’ve wasted time and effort on maintaining the problem, rather than finding the solution.

Striking a balance between patient safety and professional autonomy is a complex issue that requires a multifaceted approach. Multiple challenges stand in the way of a balanced approach, such as...

The central role played by governance and leadership in the actions (and inactions) relating to quality of care and patient safety has been repeatedly identified by inquiries and investigations into major organisational failures. They show that governance and leadership - through their influence on priorities, oversight, management and culture – are often part of both problem and solution.