Two Approaches to Patient Safety

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 The personal approach is the most encountered and outdated kind of approach in medicine.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.
Reason, J. (2000). Human error: models and management BMJ, 320 (7237), 768-770 DOI: 10.1136/bmj.320.7237.768