Is health care getting safer?BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2426 (Published 13 November 2008) Cite this as: BMJ 2008;337:a2426
All rapid responses
The paper by Vincent and colleagues echoes a familiar cry for better
data about hospital safety1 that continues to go largely unanswered.
Perhaps our approach is back-to-front. We owe a great debt to Professor
Vincent and his colleagues for emphasizing a key concept: work is done in
systems. Achieving safety is a system and good data are part of it, but
the data represent the “cart” and not the “horse”.
Safe work is done when competent people supplied with adequate
resources implement systems based on evidence. Competence implies
knowledge, judgment and technical skill. After good training programs
(also a system) it is probable that the development and use of simulators
has a great deal to offer in enhancing competence and in testing for its
maintenance.2 Regular mandatory mortality and morbidity meetings3,4
complemented if necessary by independent audit5 seem to be powerful ways
of enhancing safe practice. Surely governments can mandate and
practitioners can formalize these activities and their reporting so that
both safety and data improve.
There is a growing body of evidence concerning safe practices, now
commonly provided as bundles, and the UK NHS has made an impressive
start.6 But it needs to be improved progressively. For example, we do not
know enough about the transmission of a number of organisms causing
hospital-acquired infections. Also, there are gaping holes in some
existing bundles. As a recent Letter has indirectly pointed out,7 it is
not a Hawthorne effect as is often reported that improves surgical site
infection rates when there is feedback, it is that surgeons start to take
more care with wound closure. Wound closure is something that is lacking
in current bundles. Of course we need better evidence and health
departments could structure their data collection with this objective in
mind rather than inflicting more and more key performance indicators
(KPIs) on harassed staff. And we need to institute methods of sequential
learning such as Bayesian Networks for the analysis of these data.
Crucially, resources must be considered. In Australia we know that
one of the greatest single impediments to hospital safety is
overcrowding.8 Clinicians have little or no control over this. It does not
matter how much KPI data we collect, our hospitals have very limited
capacity to become safer until a solution is found to this very difficult
system problem that currently we seem to have no idea how to deal with.
Our quest should be for safer systems based on better evidence and if
we go about this properly we should succeed in having safer hospitals and,
as an added bonus, better data.
1. Vincent C, Aylin P et al “Is health care getting safer?” BMJ
2. Foote C “Simulation for Team Crisis Management Training in
Critical Care - Where Have We Been, Where Are We Now and Where Are We
Going?” in Australian Anaesthesia Ed Riley R 2007 Melbourne Australian and
New Zealand College of Anaesthetists pages 87-94.
3. Singer A “Mandatory regular meetings of hospital staff would
complement medical audit and revalidation” BMJ 2000;320:1072.
4. Singer A “The Bristol Affair – a view from New York” Annals of the
Royal College of Surgeons of England (Supplement) 2001;83:306-307.
5. Thompson A and Stonebridge L “Building a Framework for Trust:
Critical Event Analysis for Deaths in Surgical Care” BMJ 2005;330:1139-
7. Mahaffey P Letter Surgical Site Infection “Guidelines or
misguidance?” BMJ 2008;337:a2578.
8. Bland B “Underfunding of Australian health system leads to 1500
unnecessary deaths a year, doctors say” News BMJ 2008;337:1193.
Anthony Morton MSc(Appl),MS,MD.
Competing interests: No competing interests