FEATURE PATIENT SAFETY 017
IN SHORT Applying lessons learnt from aviation can help improve patient safety in healthcare Covering topics such as: Leadership, Situational awareness, Decision making, Communication, Personal limitations (stress, fatigue) in a TRM training programme can increase safety and productivity Sharing insight and information or constructively challenging colleagues should be viewed positively and be rewarded appropriately
has not fulfilled the intended purpose, because patients continue to experience adverse events and medical mishaps at alarmingly high rates. Every year in the UK, the NHS helps more than a million people
with health problems to get better. However, occasionally things go wrong and sometimes patients are harmed. Many of these incidents are preventable by identifying system failures and then changing them. To do this it is vital to know what kind of incidents happen and what the underlying causes are. Statistics from UK healthcare inform us that with a population of
around 60 million: Adverse events occur in around 10% of hospital admissions or at a rate of an estimated 850,000 adverse events a year Adverse events cost approximately £2 billion a year in additional hospital stays alone Around 1150 people who have been in contact with mental health services commit suicide every year 400 people die or are seriously injured in adverse events involving
medical devices every year. A review of 1014 records conducted by Professor Charles
Vincent and a team of academic medics found that: 10.8% of patients experienced an adverse event 50% of the events were preventable 33% of adverse events led to moderate, or greater disability, or death. This research, although a relatively small-scale project,
confirmed the 10% headline figure for adverse events, which has been the mean of many studies since Harvard started looking at the issue in 1991. The research team developed criteria to demonstrate that a high percentage of these adverse events were preventable. Patient Safety is of increasing public concern for consumers of
healthcare. Whether healthcare is less safe today than it was 10 years ago is a debatable question; however, there certainly is a loss of public confidence in the ability of the healthcare system to provide safe services and there is undoubtedly room for some introspection.
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