Improving Patient Safety: Insights from American, Australian and British HealthcareBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7406.109-a (Published 10 July 2003) Cite this as: BMJ 2003;327:109
What ensued when a medical devices officer decided to explore the cupboards at his hospital is one of the most attention grabbing parts of this book. Chris Quinn, from Newcastle upon Tyne Hospitals NHS Trust, found more than 40 types of infusion pump, 25 of which were obsolete, and discovered that no nurse had had competency based training in their use. An increase in the number of infusion incidents from 1993 to 1996 at the trust has now been reversed, thanks to a training programme and the growth of what Mr Quinn describes as “a culture of safety.”
Eds Stuart Emslie, Kirstine Knox, Martin Pickstone
Emergency Care Research Institute and the Department of Health, £35, pp 104 ISBN 0941417751
The theme of a safety culture runs through the book, which comprises abridged transcripts of presentations at a conference to introduce the UK's National Patient Safety Agency in 2001 and is edited by the speakers. The first few presentations are concerned with steps taken by the NHS since 2000 to emphasise the safety of patients, and with the launch of the National Patient Safety Agency. For example, Stuart Emslie, the then head of controls assurance at the Department of Health, outlines the new national system for learning from adverse incidents in the context of the governance and controls assurance agenda. He adds that it could be argued that under-investment in health service management is a major factor in the high incidence of preventable harm to patients. Another contributor, health minister Lord Hunt, points out that prolonged hospital stays as a result of adverse events cost the NHS at least £2bn ($3.2bn; €2.8bn) a year.
Contributors from the United States, Australia, and New Zealand add an international dimension to the book. Dr Paul Barach, from the University of Chicago's Center for Patient Safety, talks of improving safety of patients by “replacing the fragmented approach by teamwork and inviting the patient into the system,” while Dr James Bagian, director of the Veterans Health Administration's National Center for Patient Safety, warns of the potentially dire consequences of failing to protect the confidentiality of people making reports. He says that when New Zealand's civil aviation authority revealed the name of a captain who had made a report, it lost the trust of the aviation community and was disbanded. Professor Bill Runciman, president of the Australian Patient Safety Foundation, discusses improvements in the prescribing of non-steroidal anti-inflammatory drugs and the use of pulse oximeters.
The book is particularly strong on solutions to patient safety problems. Some parts are starting to look dated–for example, on the work of the National Patient Safety Agency, as many developments have taken place since October 2001–but overall the book is a valuable read for people who are thinking about and implementing measures to implement patient safety.
A colleague of PA on the board of the Health Care Risk Report is Stuart Emslie, one of the book's editors.