We have tended to focus on problems in isolation, one harm at a time, and our efforts have been simplistic and myopic.
To significantly reduce patient harm, we need to adopt a holistic, systematic approach that extends across cultural, technological and procedural boundaries - one that is based on the evidence of what works.
Taking its lead from developments in highway and airline safety, the report* argues in favour of a holistic approach, integrated systems, comprehensive risk assessment and performance reporting, regulation and the creation of a "science for safety".
How can we balance procedure, patients, practice, drug delivery connections, cost, staffing and technology... How can we elevate care, competency, compassion, communication, commitment, courage and values between individual and group levels?
Having agreed and identified the essential sources of evidence (humanistic and mechanistic), how can we integrate them?
Ara Darzi (2015) Patient safety needs to be improved. Health Service Journal, 13 February. 125: 6434, p.18.
*Transforming Patient Safety: A Sector-Wide Systems Approach
Peter J Pronovost, Alan D Ravitz, Robert A Stoll, Susan B Kennedy
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