Patient safety and quality improvement
Healthcare can cause harm. Patient safety science studies why errors happen and how systems can prevent them. For study only, not clinical guidance: always follow your programme, current local protocols, and supervising clinicians.
The scale of harm
The 1999 US Institute of Medicine report 'To Err Is Human' estimated that tens of thousands of Americans died each year from medical errors, launching the modern patient safety movement. The WHO estimates that around 1 in 10 patients is harmed in healthcare, and that a large share of this harm is preventable.
Systems thinking
Most errors result from flawed systems rather than careless individuals. James Reason's 'Swiss cheese model' shows how harm occurs when holes in several layers of defence line up. Safety improves by adding and strengthening barriers, not just by blaming the person at the end of the chain.
Just culture
A just culture distinguishes human error (an inadvertent slip, managed by consoling and fixing systems), at-risk behaviour (drifting from safe practice, managed by coaching), and reckless behaviour (consciously disregarding substantial risk, which warrants discipline). It encourages reporting of errors and near misses.
Near misses and incident reporting
A near miss is an error caught before it reaches the patient. Reporting near misses and incidents helps organisations find weaknesses before harm occurs. Sentinel events are unexpected occurrences causing death or serious harm, such as wrong-site surgery, which require thorough investigation.
Root cause analysis
Root cause analysis (RCA) investigates serious events to find underlying system causes rather than stopping at 'human error'. Teams ask repeatedly why something happened (the 'five whys') and develop action plans. Strong actions change systems, such as redesigning equipment; weaker actions rely on training and reminders.
Quality improvement methods
Quality improvement uses data to make care better. The Plan-Do-Study-Act (PDSA) cycle tests small changes, studies results, and refines them. Lean and Six Sigma methods reduce waste and variation. Run charts track measures over time to see if changes lead to improvement.
QSEN competencies
The Quality and Safety Education for Nurses (QSEN) project defines six competencies for nurses: patient-centred care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. They are widely used in nursing education to prepare nurses for safe practice.
Worked example
A nurse nearly gives a patient a medication meant for someone with a similar name in the next bed, catching it during the identification check. She reports the near miss. The team's review finds similar names were placed side by side; the unit introduces 'name alert' stickers and avoids assigning similar names to adjacent beds, a system fix rather than just a reminder.
Key takeaways
'To Err Is Human' (1999) launched the patient safety movement; around 1 in 10 patients is harmed in care. Most errors come from system flaws, as the Swiss cheese model shows. Just culture separates human error, at-risk behaviour, and recklessness. Report near misses and investigate sentinel events. Root cause analysis seeks system causes; strong actions redesign systems. PDSA cycles test improvements. QSEN defines six safety competencies.
Flashcard
1999 US report on medical errors
Check your understanding
According to the Swiss cheese model, how does patient harm usually occur?