Introduction to Patient Safety

Malcolm Pradhan

Preventable harm in healthcare has been an active area of research in the last 10 years that has improved our understanding of why medical errors occur. A convenient framework for understanding factors related to the pathogenesis of preventable harm was developed by Vincent and colleagues [1] and comprises:

1. Institutional factors, such as the development and use of protocols and policies, the recruiting, training and rostering of staff, the availability and adequacy of supervision, the supply and storage of materials and funding.
2. Organisational and management factors, such as organisational culture and management structure. Organisational or corporate culture may encourage adverse outcomes with a "press on regardless" approach such that poorly prepared patients are still exposed to high-risk procedures. Management decisions will influence the availability and condition of equipment and infrastructure, as well as the number and expertise of staff employed.
3. Work environment factors, for example excessive workloads, inadequate training and skills for certain tasks, equipment availability and maintenance.
4. Team factors, such as team structure and communication.
5. Task factors, for example availability of information, task complexity. These factors may be emphasised by time limitations, poorly designed or impractical protocols or checklists or excessive false alarms that may induce a health care worker to take a short cut or respond inappropriately in a potentially hazardous situation.
6. Patient factors, such as comorbidities, language and communication. The more complex a patient's care, the more likely the interaction between different factors will lead to an adverse outcome.

Institutional and organisational factors, and human factors that lead up to an event are often termed 'latent' factors [2] . In addition, reason produced a model of process-related factors that lead to preventable error, which we have adapted to highlight the factors listed above (Figure 1).

Figure 1. Factors for the pathogenesis of preventable harm.

Figure 1 reveals that a combination of factors permits hazards to become actual losses, harm or injury; these include both errors in judgement and knowledge, and problems in healthcare processes. Commonly preventable errors in healthcare have been viewed as the fault of individuals rather than the result of a complex set of systemic problems. It is interesting to note that most quality initiatives such as practice guidelines, and the entire evidence-based medicine (EBM) movement, target implicitly so-called 'human factors,' that is, the cognitive and knowledge deficiencies of healthcare professionals. While human reasoning is well documented as fallible [3] , the assumption of many practice improvement movements is that practice variation and sub optimal patient outcomes are due to the failing of the individual practitioner to keep up with the literature and to apply 'best evidence'. Problems due to systemic failures and poor quality processes are often overlooked by traditional approaches to practice improvement - it is easier to blame an individual rather than try to understand a complex system of interactions.

1. Vincent C, Adams S, Stanhope N. A framework for the analysis of risk and safety in medicine. British Medical Journal 1998;316:1154-7.
2. Reason J. The contribution of latent human failures to the breakdown of complex systems. Philosophical transactions of the Royal Society of London. Series B: Biological sciences. 1990;327(1241):475-84.
3. Tversky A, Kahneman D. Judgment under uncertainly: heuristics and biases. Science 1974;185:1124-1131.
4. Standards Australia. Risk Management (AS/NZA 4360:1999). Strathfield, NSW: Standards Association of Australia; 1999.

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