Peter Lachman (editor) - Oxford Professional Practice: Handbook of Patient Safety

Oxford Professional Practice Handbook of Patient Safety

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Oxford University Press 2022

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First Edition published in 2022

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Library of Congress Control Number: 2021945574

ISBN 978-0-19-284687-7

eISBN 978-0-19-266232-3

DOI: 10.1093/med/9780192846877.001.0001

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Helen Haskell, Hussain Jafri, and Margaret Murphy

WHO Patients for Patient Safety Advisory Group

Patient safety is a field with many moving parts. It cuts across disciplines, professions, healthcare systems, business sectors, and governments. It ranges from the simple to the complex, from the intimately personal to the broadly theoretical. Perhaps more than any other area of healthcare, it embraces multiple and sometimes incompatible models of management, which have themselves evolved and changed over the years with surprising fluidity.

This sprawling combination of the philosophical and the practical is the necessary underpinning of healthcare. Without patient safety, medical treatments lose their purpose. Care flounders and can become its opposite: a source of harm. In all too many instances, in all too many parts of the world, this occurs on a regular basis. As patient leaders in patient safety, we are in a position to see the sad outcomes. For patients, safety can be everything.

In spite of the fact that patient safety is a relatively young field, there has been concern in recent years that it has ceased to be a priority of the healthcare establishment, especially in higher-income countries. Several global initiatives have aimed to reverse that trend, among them the 201419 Global Ministerial Summits on Patient Safety (interrupted by COVID-19 in 2020); the 2020 G20 Declaration, which names patient safety as a global priority; and the Global Patient Safety Action Plan approved by the World Health Assembly in 2021. The underlying concept is that healthcare must be made safe if the goal of universal healthcare is to have real meaning.

The goal of the present book is to address this gap by laying out the components of patient safety in a readable, yet comprehensive fashion, in a practical work of reference for anyone involved in healthcare. Its chapters include straightforward solutions that can be adopted and practised even in low-resource environments; these solutions include details of process, hygiene, medication safety, and communication. An important thread is formed by the concepts of teamwork and of flattening the hierarchy so that all can speak up for safety. Even more important is the emphasis on the role of the patient in both enabling and producing healthcare.

Why is patient engagement so important? Because, in the end, patient safety is about patients. Healthcare professionals cannot make healthcare safe without knowing what their patients experience, or without the insights and observations of patients regarding their processes and treatments. For patients, it is critical to learn to educate themselves and to advocate their own safety and that of their family members. Patients cannot, however, make themselves safe without the help of their healthcare providers. Only together can we achieve our goals.

As patient safety continues to evolve, the combined wisdom of patients and providers may yet turn out to be the major element that allows it to progress towards its goal of (dare we say it?) zero harm. This handbook, with its combination of practicality and forward thinking, is an indispensable guide along the way.

Ahmeda Ali

General Practitioner and Assistant

Director of Dublin Northeast ICGP Training Scheme

Irish College of General Practitioners

Dublin, Ireland

Chapter: The culture and system of patient safety

Jay Banerjee

Consultant in Geriatric Emergency Medicine

University Hospitals of Leicester NHS Trust

Leceister, England

Chapter: Safety in the emergency department

Rob Bethune

Consultant Surgeon

Royal Devon and Exeter NHS Foundation Trust

Exeter, England

Chapter: Safety in the operating theatre

Pallavi Bradshaw

Deputy Chief Medical Officer

AXA Health

London, England

Chapter: Open disclosure

Jeffrey Braithwaite

Professor and Founding Director

Australian Institute of Health Innovation, Macquarie University

Sydney, NSW, Australia

Chapter: Resilience theory, complexity science, and Safety-II

John Brennan

General Practitioner and Quality Improvement Faculty

Royal College of Physicians of Ireland

Dublin, Ireland

Chapter: Safety in primary care and general practice

Karen Britton

Lead Nurse Deteriorating Patient and Resuscitation

Frimley Health Foundation Trust

Frimley, England

Chapter: Preventing and limiting deterioration on the medical wards

Kate Churruca

Postdoctoral Research Fellow

Australian Institute of Health Innovation, Macquarie University

Sydney, NSW, Australia

Chapter: Resilience theory, complexity science, and Safety-II

Robyn Clay-Williams

Associate Professor

Australian Institute of Health Innovation, Macquarie University