Some thoughts on Patient Safety Concerns!
I was doing a bit of research on court and tribunal cases where nurses had been found failing standards or professional expectations. There are many and there were also quite a number of failures to ensure patient safety documented.
In relation to patient safety there is an enormous amount of information and this concept of course underpins the existence of protocols, procedures, training, audits and rules. One way or another it is a constant demand that we all work to ensure patient safety is always a paramount concern. The other side of that coin is working out precisely when and why the wheels fall off and patients get hurt.
By definition it is always after an adverse event or an accident that this type of research occurs. Finding fault and laying blame is a natural tendency. Researchers often discover that it was not an individual failure but a series of slips, lapses and oversights which accumulated that led to a disaster.
That is why it is important that finger pointing and blaming be delayed until a real investigation is completed. Most of us would be a bit cynical about that statement I suspect. It is just so much easier to point, blame, adjust the protocols and move on. I have written often over the years about nurse’s need to explore gaps, actual and potential so we can consciously improve systems and avoid accidents.
A somewhat dated article by Richard Cook in the British Medical Journal (2002), ‘Gaps in the continuity of care and progress on patient safety’, is one I often revisit. He proposed that our experience and knowledge is constantly being drawn upon in our very complex and stressful environment to overcome gaps. Day in and day out. So much so that we don’t even realise how often we avert disaster and prevent adverse outcomes. His premise is that exploration of gaps and the way practitioners anticipate, detect, and bridge them is worth looking at. Rather than only carrying out a retrospective accident investigations.
There are dozens of gaps or oversights or problems in any day and yet few lead to disaster or accidents. Why? Because it is part of our work, often routinely to problem solve and correct problems. We don’t get much recognition for this habit of practice but it is a pretty important part of our day’s activities. There are dozens of causes and frustratingly when we bridge a gap there is no guarantee we have eliminated it. True there are strategies such as better procedures and protocols but in such a complex environment gaps just keep reappearing.
Cook touched a nerve when he proposed that accidents occur not because practitioners failed but that they were overwhelmed in their normal, habitual and routine problem solving. He suggests that it is not our human error that leads to accidents rather it is our professional skill that manages to prevent most if not all disasters that can arise from gaps. He suggests we do need to use reports and strategies that have identified and attempted to resolve known gaps but being proactive and suspicious of a potential of a gap in patient care, history, medication orders, transfer and discharge documents is a professional skill.
Rather than simply congratulating ourselves that we are (at least by this author) recognised as terrific gap identifiers and gap solvers we should be active in developing and promoting these skills. If gaps are always going to be there and the technological and system changes are going to be constant why waste time blaming an individual for failing to see a gap, rather we should all be active in developing and maximising this inbuilt skill and attribute. We are really good at it so respect and improve on it.
There are some fabulous webinar recordings by Pam Savage regarding Nurses and the Law on the Nurses for Nurses Network . The Nurses for Nurses Network provides good information and CPD on an array of nursing topics in a range of easy learning ways including webinars and quizzes on the latest information that Nurses need to know – remember the Nurses for Nurses Network was created by Australian Nurses for Nurses ! www.nursesfornurses.com.au
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