A patient safety challenge

Dr. Peter Lachman
Dr. Peter Lachman

As I write this, the entire worldwide fleet of Boeing 737 Max 8 have been grounded because of two air crashes that were similar. Aviation authorities have taken action because of the possible unsafe aircraft and because the public demand safe air travel, writes Dr. Peter Lachman.

In health care, more people die from avoidable deaths each day than died in the two airline crashes. Yet we do not close hospitals readily and have yet to make Patient Safety a core business function of our work.

Nonetheless, Patient Safety is now an integral part of the health services environment. We talk about it frequently and newspapers write about it usually in the negative sense following an adverse event.

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Patients are demanding safe care as they demand safe air travel. I have heard many a manager say it is important, but I still do not see patient safety as being a core business function.

We complain about the system being unsafe due to increased demand and too little supply of healthcare providers. Yet we do not actively design for safety to the extent that is required. Providing safe care is complex and unfortunately unlike air travel patients have less choice on provider, on when they use the service and most do not do so out of choice.
We all need to own the problem and actively change the system, so it does become safe. The why is clear in that we should not harm people.

In health care, more people die from avoidable deaths each day than died in the two airline crashes

There is sufficient evidence available on what to do. The how to do it is more problematic. While safety has always been a challenge it is a bigger challenge now given that we have not really designed safe systems . Most of what we do is catch up.
A few weeks ago, I attended the 7th summit of the Patient Safety Movement Foundation in California. The key message for the PSMF is that patients really matter and they cannot wait for us to solve the problem some time – we need to solve it now. The aim is high – Zero Avoidable Deaths by 2020.

To achieve this, the movement has placed patients directly in the centre of what they do by using patient stories to shine a light on the need for solutions . Every session had a patient as an equal partner to the professionals.

They have developed solutions, Actionable Patient Safety Solutions (APPS) which are essential interventions to decrease the potential risk to patients of avoidable deaths. This includes enhancing a culture of safety and developing learning environments, as well as specific interventions that need to be implemented to achieve Zero. If quality improvement methodology is applied to reliably and consistently implement these APPS, then scores of lives will be saved.

Key to the movement is the safety pledge by leaders of hospitals and health systems to aim for zero. Is it not time for every CEO in Ireland and every management team to make a pledge and rise to the challenge . Every life lost is a wasted one and we now need to make patient safety the core of what we do. As the HSE develops a Patient Safety Strategy, those in the frontline need to consistently implement the solutions. Every life saved will be valued by patients and families.

I challenge all to take the pledge and make a difference.
Details on the movement are on https://patientsafetymovement.org/
The Interventions are on https://patientsafetymovement.org/actionable-solutions/actionable-patient-safety-solutions-apss/