In 2016 the British Medical journal reported medical error as the third greatest killer in hospitals.
If patient safety is to improve we need to accept that:
- an error is something we will all make
- learn how to stop errors causing adverse events
- have frameworks to put this learning in place
In this series of posts under the title ‘fixing healthcare safety’ we discuss how these steps can be achieved (click on each link in red to read the posts in full):
- Paradigm Shift – We see what we are conditioned to see. If healthcare safety is to improve we need to understand the human in the room and introduce system solutions for safety.
- Time To Pull The Andon Cord – Healthcare could learn from other industry. We need to celebrate those who expose front line safety hazards and support them to drive solutions.
- Team Of Teams – Healthcare environments have become increasingly complex. Existing error reporting systems based on traditional command structures are ineffective. We need to work as a ‘Team of Teams’.
- Flying Healthcare Safety – Healthcare is perfectly designed so that medical error is the third greatest cause of hospital death. The safety machine is broken so we’ve built a new one. Welcome to the PatientSafe Network.
- Human in the Team – We are all human and all make mistakes. We can’t change this human condition however we can change the conditions humans work within. The ‘command structure’ of healthcare makes these changes extremely difficult. If we choose to be human and part of a team just imagine the lives we could save.
- Thank You Alison Brindle – Student midwife Alison Brindle discovered a way to introduce #humanfactors understanding into #healthcare with her #TheatreCapChallenge. The further repercussions of this could save hundreds of thousands of lives. Thank you Alison Brindle.
- Back to Why – Will we see the greatest improvements in patient safety if within healthcare we simply remember why we do what we do?
- Crossing The Chasm – Current frameworks may make it impossible to introduce the changes required. For healthcare to improve we will need to work differently.
- Help – healthcare internationally functions within dominance hierarchies. These frameworks may prevent healthcare from ever fixing itself. Whatever your background, from outside healthcare, we need your help.
- Us – the problem & the solution – this video presentation takes a deeper look at what it means to be homo sapiens, how we are all part of the problem and how we can all be part of the solution.