Two Approaches to Patient Safety

Walter van den Broek
January 16, 2012

patient safety

The two approaches to patient safety are the person approach and the system approach. The personal approach is the most encountered and outdated kind of approach in medicine. In short, errors are seen as shortcomings of medical personnel such as forgetfulness, inattention, poor motivation negligence and recklessness. The response is mostly naming, blaming, and shaming. Errors are treated as moral issues assuming that bad things happen to bad people.

Seeking as far as possible to uncouple a person’s unsafe acts from any institutional responsibility is clearly in the interests of managers. It is also legally more convenient, at least in Britain.

It’s shortcoming are the lack of a reporting culture. In aviation about 90% of quality lapses are judged as blameless. Without reporting the errors, near misses and such due to the blaming culture most error traps are undiscovered. The personal approach also isolates errors from their system context. This causes errors to fall into recurrent patterns.

The personal approach is not the right practice in such complex organizations as most medical institutes are.

The system approach views humans as fallible and errors are to be expected especially in these complex organizations and professions.

Errors are seen as consequences rather than causes having their origins not so much in the perversity of human nature as in “upstream” systemic factors.

An important aspect of errors are failures in latent conditions. They result from decisions made on a different level such as the construction of procedures, the making of protocols. These decisions are usually made by designers, builders and top level management. These decisions can be at fault using the procedures, building and protocols.

To use another analogy: active failures are like mosquitoes. They can be swatted one by one, but they still keep coming. The best remedies are to create more effective defences and to drain the swamps in which they breed. The swamps, in this case, are the ever present latent conditions.

This is a summary of an important publication on patient safety. It goes into more detail about the differences between these two approaches especially with examples of other high reliability organizations such as nuclear aircraft carriers, air traffic control centers and nuclear power plants. The most important difference with medicine is the collective preoccupation with the possibility of failure.

Instead of isolating failures, they generalise them. Instead of making local repairs, they look for sys­tem reforms.

A lot of work to be done before patient safety is fully implemented in medicine.

ResearchBlogging.org
Reason, J. (2000). Human error: models and management BMJ, 320 (7237), 768-770 DOI: 10.1136/bmj.320.7237.768

 

3 Responses to “Two Approaches to Patient Safety”

  1. Hi,

    Interesting idea. But unlike nuclear submarines or airports, medicine seems more interpersonal (e.g. an ER doctor is more directly responsible for the outcome of a patient than, say, an air traffic controller is on the safety of a plane landing at the airport).

    My question is whether using a systemic approach to medicine diminishes or cuts off the personal ties from doctor and patient. Perhaps doctors feel less compelled to double-check on the status of their patients, because they think a system is in charge of the process. So, while intending to reduce negligence, systemized medicine diminishes the relationship between patient and doctor. For instance, in the case of an oncologist and cancer patient, the relationship can be very important, as it may help guide doctors to making more difficult, laborious, and ultimately beneficial procedures.

    Just a thought. But overall systemized medicine seems to have its advantages. Which would you prefer if you were a patient? And would systemized medicine work in psychiatry (e.g. quicker patient recoveries), despite privacy laws that currently exist?

  2. Matt on January 17th, 2012 at 5:06 am
  3. You’re right, the system should not be used to diminish the ties with the patient. The most important thing for doctors to realize is that they make mistakes no matter what. Being aware of this is the most important part of patient safety. So they should always focus on the patient and be assured that the system doesn’t blame them since errors happen especially in complex situations with complex diseases. The system approach is more about dealing with the errors. A shift from naming, blaming and shaming to an awareness and proper dealing with mistakes in order to prevent them.
    Take care Dr Shock

  4. Dr Shock on January 17th, 2012 at 10:23 am
  5. 1} A system can never be in charge of processing in healthcare.It takes responsability away and the blame goes to the patient because he is not “standard”.

    2} with responsability coming back the urge to detect flaws and prevent errors makes healthcare not only a lot safer but also knowledgeable.

  6. C.A Potters on January 19th, 2012 at 9:16 pm
  1. Hi,

    Interesting idea. But unlike nuclear submarines or airports, medicine seems more interpersonal (e.g. an ER doctor is more directly responsible for the outcome of a patient than, say, an air traffic controller is on the safety of a plane landing at the airport).

    My question is whether using a systemic approach to medicine diminishes or cuts off the personal ties from doctor and patient. Perhaps doctors feel less compelled to double-check on the status of their patients, because they think a system is in charge of the process. So, while intending to reduce negligence, systemized medicine diminishes the relationship between patient and doctor. For instance, in the case of an oncologist and cancer patient, the relationship can be very important, as it may help guide doctors to making more difficult, laborious, and ultimately beneficial procedures.

    Just a thought. But overall systemized medicine seems to have its advantages. Which would you prefer if you were a patient? And would systemized medicine work in psychiatry (e.g. quicker patient recoveries), despite privacy laws that currently exist?

  2. Matt on January 17th, 2012 at 5:06 am
  3. You’re right, the system should not be used to diminish the ties with the patient. The most important thing for doctors to realize is that they make mistakes no matter what. Being aware of this is the most important part of patient safety. So they should always focus on the patient and be assured that the system doesn’t blame them since errors happen especially in complex situations with complex diseases. The system approach is more about dealing with the errors. A shift from naming, blaming and shaming to an awareness and proper dealing with mistakes in order to prevent them.
    Take care Dr Shock

  4. Dr Shock on January 17th, 2012 at 10:23 am
  5. 1} A system can never be in charge of processing in healthcare.It takes responsability away and the blame goes to the patient because he is not “standard”.

    2} with responsability coming back the urge to detect flaws and prevent errors makes healthcare not only a lot safer but also knowledgeable.

  6. C.A Potters on January 19th, 2012 at 9:16 pm
  1. Hi,

    Interesting idea. But unlike nuclear submarines or airports, medicine seems more interpersonal (e.g. an ER doctor is more directly responsible for the outcome of a patient than, say, an air traffic controller is on the safety of a plane landing at the airport).

    My question is whether using a systemic approach to medicine diminishes or cuts off the personal ties from doctor and patient. Perhaps doctors feel less compelled to double-check on the status of their patients, because they think a system is in charge of the process. So, while intending to reduce negligence, systemized medicine diminishes the relationship between patient and doctor. For instance, in the case of an oncologist and cancer patient, the relationship can be very important, as it may help guide doctors to making more difficult, laborious, and ultimately beneficial procedures.

    Just a thought. But overall systemized medicine seems to have its advantages. Which would you prefer if you were a patient? And would systemized medicine work in psychiatry (e.g. quicker patient recoveries), despite privacy laws that currently exist?

  2. Matt on January 17th, 2012 at 5:06 am
  3. You’re right, the system should not be used to diminish the ties with the patient. The most important thing for doctors to realize is that they make mistakes no matter what. Being aware of this is the most important part of patient safety. So they should always focus on the patient and be assured that the system doesn’t blame them since errors happen especially in complex situations with complex diseases. The system approach is more about dealing with the errors. A shift from naming, blaming and shaming to an awareness and proper dealing with mistakes in order to prevent them.
    Take care Dr Shock

  4. Dr Shock on January 17th, 2012 at 10:23 am
  5. 1} A system can never be in charge of processing in healthcare.It takes responsability away and the blame goes to the patient because he is not “standard”.

    2} with responsability coming back the urge to detect flaws and prevent errors makes healthcare not only a lot safer but also knowledgeable.

  6. C.A Potters on January 19th, 2012 at 9:16 pm

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