Promoting patient safety

Promoting patient safety goes hand-in-hand with person-centred care. A whole new science has grown up around patient safety to try to explain the many circumstances, situations and occurrences that can put patients at risk.  It may not be a single issue that causes the problem, but  a combination of factors.

It might help if we take an example from a hospital. Here’s a list of things that happened at a particular time on a particular shift.

  • the charge nurse was on holiday and an inexperienced staff nurse was in charge
  • the ward cleaner went to the toilet after cleaning the corridor floor
  • three of the ward’s six nursing staff on shift were on their tea break
  • Mr Anderson, an 85-year-old gentleman with dementia, thought he heard someone call his name outside his room.

Nothing exceptional here, perhaps, but let’s begin to flesh it out and see how these events conspired to threaten a patient’s safety.

  • the ward cleaner went to the toilet after cleaning the corridor floor, leaving the floor wet and with no sign to warn people of this fact
  • Mr Anderson, a 85-year-old gentleman with dementia, thought he heard someone outside his room, so, forgetting to use his walking frame or to put his shoes on, walked into the corridor in his stocking soles and slipped on the wet floor, falling onto his hip
  • three of the ward’s six nursing staff on shift were on their tea break, so no staff were around to remind Mr Anderson to put his shoes on and take his walking frame, or to recognise the risk the wet floor in the corridor posed
  • the charge nurse was on holiday and an inexperienced staff nurse was in charge, who recognised that the hospital management always looked for someone to blame when there was an accident like this so decided, after helping Mr Anderson back to his bed,  to ignore hospital protocol and not report the incident.

At this point, we do not know if Mr Anderson is seriously hurt or not. But what is clear is that his safety  has been placed under threat by a number of factors:

  • human failure: the ward cleaner’s forgetfulness  and the staff nurse wilfully ignoring hospital protocols
  • management failure: the decision to allow three nursing staff to go on break at the same time left the ward with insufficient staff to ensure patients’ safety
  • organisational failure: the hospital’s culture of punishing staff for mistakes, rather than seeing each accident or mistake as an opportunity for learning that could improve services throughout the hospital, acted as a strong disincentive for the staff nurse to follow standard protocols and seek urgent medical assistance for Mr Anderson.

It is this combination of factors, put together in sequence, that led to the initial problem (Mr Anderson’s unobserved fall) and the subsequent threat to his safety and well-being (the staff nurse’s reluctance to respond appropriately). It’s therefore important that we try to think in terms of combinations and sequences when thinking about potential threats to  patient safety by, for example:

  • not just observing that a meal served to a patient has large chunks of uncut meat, but also linking that to your awareness that the patient receiving the meal has trouble chewing and may choke if the food is not prepared in smaller pieces
  • not just  observing a long electric cord crossing the floor of a patient’s living room, but also linking this to the patient  having problems with walking and the cord crossing in front of the main door to the kitchen, meaning she could trip over it the next time she goes to make a cup of tea
  • not just observing that a child in your care is uncharacteristically quiet today and seems a little fretful, but also reporting this to the person in charge who can then ensure the child is properly examined and appropriate action taken
  • not just observing that the young man you are visiting at home seems to be responding to a voice that you cannot hear, but also linking that to your awareness that he has a mental health condition that can cause him to hear “voices” (what we call auditory hallucinations) and that this symptom can arise when he fails to take his treatment appropriately
  • not just observing that the woman you are supporting to take a walk outside is beginning to become restless and  agitated, but also linking this to your knowledge that she has a learning disability, suffers from agoraphobia (you might have heard of this as a condition in which the person has fear of open spaces, but it can also reflect a fear of being in situations where escape might be difficult or help wouldn’t be available) and is currently taking part in a phased programme to try and help her to feel more comfortable when she leaves her supported living accommodation.

A number of tools have been developed specifically to help health care workers promote patient safety. One of these, the National Early Warning Signs (NEWS) tool, helps staff to identify early signs that a patient’s condition is worsening and that urgent attention may be required. NEWS, which was jointly launched by the RCN and Royal College of Physicians, consists of a bedside chart staff can use to monitor patients and summon help when necessary. It can be used in hospitals and community settings.

Safety is an issue we will return to in a number of parts of this resource and provides another underpinning element to our daily practice. If you would like to learn more about the theories and ideas that help us to understand threats to patient safety better, you can visit the RCN clinical topic page: Patient safety and human factors.

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