Resources

Many years on from the Mid Staffordshire report, avoidable patient harm continues to occur in the UK (and the rest of the world). There continue to be new inquiries and reviews into serious patient safety scandals, all with recurring themes, including failure to listen to patients or learn from previous investigations, a corrosive blame culture, a lack of effective leadership and an unresponsive regulatory framework.

The Institute of Medicine (IOM) reports ‘To Err Is Human’ and ‘Crossing the Quality Chasm’ prompted healthcare leaders to address the patient safety crisis by advancing the systems, teamwork and improvement science needed to deliver safer care to patients. 

Health and human services’ managers, practitioners and policymakers all over the world are exploring the impact of Artificial Intelligence (AI). This commentary piece summarises a comprehensive report, co-authored by McKinsey Co. and the European EIT Health think-tank, on the potential impact of AI in healthcare. They use the European Parliament definition of AI as ‘the capability of a computer program to perform tasks or reasoning processes that we usually associate with intelligence in a human being.’

Where to from here with patient safety? 13 global leaders working in different roles — healthcare delivery, government, consulting — and in different countries, identify key barriers and drivers for improving safety and accelerating progress.

Leadership is a key driver of healthcare worker well-being and engagement.  This study sought to evaluate healthcare worker leadership behaviours in relation to staff burnout, engagement and safety culture across 31 US hospitals, with the findings applicable across human services.

Surgical site infections remain a problem despite many decades of research and practice change to eliminate those that are preventable. 

Approximately 0.5% to 3% of surgical patients develop an infection. Compared with patients undergoing surgery who do not have a surgical site infection, these patients are hospitalized approximately 7 to 11 days longer.   As we know, longer hospital stays increase the risk for patients and reduce hospital efficiency and effectiveness. Infections are the leading cause of re-admissions following surgery and can add thousands of dollars to the cost of an admission. 
 

We think of consumer safety primarily in terms of physical harm. But consumers often conceptualise safety as ‘feeling safe’, as well as ‘being safe’.  

Violating a consumer’s emotional safety while avoiding physical harm is not yet embedded in consumer safety reporting. We know that consumers can experience emotionally harmful experiences as they navigate health services, such as: disregard for their opinion, not being listened to, rudeness and abuse. Are we doing consumers and families a disservice by ignoring or denying harm that doesn’t fit our organisational definition?

It is 10 years since Robert Francis presented the report on the public inquiry into failings at Mid Staffordshire NHS Foundation Trust. The government’s response signalled a determination for change. It promised wide-ranging interventions and legal and regulatory reforms to tackle problems of culture, openness, and willingness to learn. What is the impact 10 years on?

Staff and consumer satisfaction are interdependent. But in human services, we often address them separately – or think that one comes at the expense of the other. But high-performance organisations think differently.

Root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives.