We are now half-way through the journey in this blog which is all about two related themes – human error and patient safety. So far, we have focussed on the first theme and discussed the four foundations of human error – the cognitive, the behavioural, the clinical, and the systemic. Our 42 published blog posts have highlighted the broad spectrum of topics that come under the remit of human error such as:
As we turn our attention to the second theme of this blog, patient safety, our starting point will be the patient safety incident. This is defined by the World Health Organisation (WHO) in its document titled The Conceptual Framework for the International Classification for Patient Safety: Version 1.1 Final Technical Report as ‘an event that could have resulted, or did result, in unnecessary harm to a patient’. An adverse event on the other hand is defined by Carol Liebman and Chris Hyman, in their paper titled A mediation skills model to manage disclosure of errors and adverse events to patients, as ‘an unintentional, definable injury that was the result of medical management and not a disease process’. An adverse event is also defined by Heather Sherman and colleagues, in their paper titled Towards an International Classification for Patient Safety: the conceptual framework, as a patient safety incident that results in actual harm.
Patient safety incidents have wide ramifications for patients, their families, the affected healthcare professionals, and the organisation as a whole. There are therefore various dimensions to patient safety incidents, and in the next few weeks we will explore the following themes:
- The most egregious patient safety incidents
- Responding to patient safety incidents
- Patient safety incident disclosure
- The investigation of patient safety incidents
- Apology for patient safety incidents
- The non-confrontational resolution of patient safety incidents
- Compensation and forgiveness following patient safety incidents
- Non-judicial approaches to resolving patient safety incidents
- Litigation following patient safety incidents
- The second victim of patient safety incidents
- Training and support for dealing with patient safety incidents
Stay tuned therefore as we begin next week with the most egregious patient safety incidents.