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Quest for patient safety in a challenging environment
Author(s) -
Court Denys
Publication year - 2003
Publication title -
australian and new zealand journal of obstetrics and gynaecology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.734
H-Index - 65
eISSN - 1479-828X
pISSN - 0004-8666
DOI - 10.1046/j.0004-8666.2003.00044.x
Subject(s) - blame , presumption , safer , harm , patient safety , near miss , work (physics) , adverse effect , event (particle physics) , liability , public relations , medical emergency , psychology , business , medicine , risk analysis (engineering) , health care , computer security , social psychology , political science , computer science , law , forensic engineering , engineering , accounting , mechanical engineering , physics , quantum mechanics
We are unable to guarantee our patients that the care we provide will do no harm. Up to 16% of hospital admissions will be associated with an adverse event, approximately half of which are preventable. It is a clinical imperative that we must strive to improve patient safety by improving the systems in which we work, such that they support us in providing better and safer care. For this to occur, an environment must develop where clinicians feel safe to report and allow analysis of adverse events and near misses. The greatest inhibitor of a reporting culture is the prevailing legal climate with its associated blame culture. A new social contract is required whereby systems analysis will predominate over the previous presumption that individual clinicians must be held responsible for each and every adverse outcome. Individual responsibility should be reserved for events where it becomes evident during the course of systems analysis that an individual's behaviour is truly blameworthy.