Why we need a re-think of patient safety practices

Introduction

There is no doubt patient safety in our health care facilities is a global priority. Worldwide, we continue to see high numbers of patients suffering harm, or at worst, death, related to unsafe care and these risks are amplified in low and middle-income countries (World Health Organization, 2021). This is of concern given that a significant proportion of these adverse events are avoidable (World Health Organization, 2021). Global reports outline more than three million deaths annually due to unsafe care (Slawomirski et al., 2020). Many of these events occur within healthcare environments where targeted, group-specific and systematically developed prevention strategies have been implemented.

In 2021, the World Health Organization (WHO) (World Health Organization, 2021) formulated ‘The Global Patient Safety Action Plan 2021-2030’, recognising patient safety as a top health priority. In this report, patient safety is viewed as a framework of activities that address cultures, processes, procedures, behaviours and technologies with the aim of creating an environment whereby the potential for preventable harm to occur is reduced, errors are made more unlikely, or at minimum, their impact is lessened.

Nurses’ safety decision opportunities

Almost all safety initiatives implemented in health care settings are based on Donabedian’s conceptual model of quality care (Donabedian, 2005), which assumes a linear approach using the dimensions of ‘structure’, ‘process’, and ‘outcome’ to improve quality care. This has resulted in numerous structures and associated processes being embedded within the frameworks of quality and risk management systems. Persistently, despite these efforts, late detection of clinical deterioration, falls, pressure injuries, medication errors and many other sources of harm still exist inside the safety nets of these quality governance structures, policies, and processes.

Safety processes performed

Enquiry into why patients are still slipping through the safety nets has now become essential. Are the issues quality system implementation processes, failed intervention uptake by clinicians, or are already implemented safety systems themselves just not making any difference to patient outcomes?

When safety programmes are introduced, they impact clinicians’ routine practice. The implications for this practice change may not always be conceived as resulting in better or safer care. For instance, one of the most universally successful (in respect to uptake) safety strategies is the Rapid Response System (RRS)/Medical Emergency Team (MET). Designed with early detection and intervention of clinical deterioration in mind, these ‘reactionary’ initiatives, as with many other implemented safety systems, are in fact creating unexpected sequelae within the clinical setting. Literature reports the de-skilling, and to some degree, loss of autonomy and decision-making of the nursing workforce post-rapid response implementation. Medical-surgical nurses may frequently rely solely on the five vital signs alone to determine the health status of patients (the required data trigger for initiating RRS) (Douglas et al., 2016).

Arguably, the fundamental skills of the registered nurse are in performing comprehensive structured patient assessments, and engaging in clinical reasoning and decision-making to proactively maintain patient safety. Consequently, in an effort to use RRS to address the issue of unrecognised deterioration, inadvertently in some clinical settings, nurses have replaced a practice of comprehensive assessment with an alternative, less holistic vital signs ‘routine’ (Osbourne et al., 2015). The integration of this system as a tool supporting the traditional full scope of practice isn’t occurring.

The RRS is not a unique example, nurses are becoming increasingly required to complete and report on large amounts of quality governance-driven work, often in the form of stand-alone assessments/audits, in order to justify accountability of care. This can be overly burdensome and time-consuming and form a large component of day-to-day ‘nursing work’.

No doubt this is strongly underpinned by legal requirements to provide evidence protection for healthcare providers. This wicked problem is not new; however, close to a decade ago Kieft et al. (2014), when describing policy and transparency for external accountability, mentioned nursing pressures to increase productivity through reporting high administrative workloads. The consequences of all this ‘re-direction’ of nurses’ traditional workflow, are felt most at the micro-ward level where the focus is increasingly turning away from the patient’s bedside.

Foundational skills and knowledge are being potentially discarded for shift efficiencies and ‘tick a box’ or ‘task focused’ care, providing ‘evidence’ for performing ‘safe care’. Clinicians talk about abandoning traditional safety practices such as comprehensive patient assessment because of a lack of time and over-reliance on others and technology (Douglas et al., 2014).

The concept of ‘performing safety’ by integrating these systems into learnt knowledge and ways of working at all levels has become amiss. Initiatives are often introduced as solitary entities, without good practice integration and a disregard for clinicians’ traditional ways of holistic approaches to care. There is, therefore, great potential for fragmented, dissociation of the ‘whole of patient’, which could affect consequent decisions or plans of care and missed opportunities to prevent harm.

Non-integration means comprehensive care is compartmentalised. The problem itself may not be the initiatives, but indeed the implementation processes and their resulting impact, which at times, conflict with how clinicians are trained to work. Only implementing from ‘the top down’, with a one-size-fits-all approach will result in failure to convince clinicians of the value of these initiatives and/or make it difficult to embed without consideration of workplace environments, workflows and cultures.

Challenges and opportunities

When interventions and programmes are implemented through mandated directives, little to no consultation with clinicians occurs. This is missed opportunity as they are likely to have experiential ideas on how best to integrate into practice and up-scale for a broader appeal (Van Veenendaal et al., 2018).

There could be a re-think from all levels (macro to micro) of the healthcare system, as to how better to implement safety practices. Better use of implementation science strategies may provide additional support for embedding and also aid in longer-term sustainability (Sarkies et al., 2022).

Evidence-based methods, tools, approaches and strategies to assist in successful safety programme implementation, are not often seen as currently being done well in the clinical setting (Feldman et al., 2018). How much consultation and facilitation of large state and national programmes are done at each local site prior to implementation? New initiatives are often ‘directives’ backed up by policy with little room for site-specific modification to fit local needs, cultures and contexts. Audit and feedback are also poorly done (Livorsi et al., 2018) again, often without evidence-based strategies to engage clinicians in identified problems to drive and achieve practice change.

Quality systems with a theory?

This description makes clear that quality systems (structures, processes) to strengthen patient safety must take place in harmony with the organisational culture of the hospital.

As a characteristic of the organisation, not of the individual, organisational culture reflects existing safety culture. A safety culture is visible in the way safety and risks are dealt with and in the behaviour of those involved – seen as a psychological phenomenon that includes norms, values, and beliefs (Ausserhofer et al., 2012).

An organisational culture that prioritises safety enables safety-oriented management, decision-making and staff behaviour that supports learning from mistakes and increases the organisations’ ability to adequately deal with risks that arise or have arisen (Schrappe, 2017) Thus, it can be seen that organisational culture and active support from hospital management have a key role in promoting and sustaining safety culture (Levine et al., 2020). ‘High reliability organisations’, where this has been achieved, have been able to implement effective change despite the complexities and high-risk nature of their organisations (Sutcliffe et al., 2017).

Current quality assurance systems are mostly implemented selectively, without conceptual underpinnings. There is a lack of embedding in the overall system of an organisation as well as the people involved and consideration of resources and needs.

The General Systems Theory (GST) laid the foundation for talking about things in terms of systems and creates the basis for a wide range of systems’ approaches and systems’ thinking (Johnson, 2019).

It is timely to undertake a review of implemented safety initiatives. Emerging from the COVID-19 pandemic, nursing workforce attrition and retention are adding to an already recognised workforce crisis (World Health Organisation. Nursing and Midwifery, 2022). Many nurses that have remained are tired, exhausted and burnt out. Continuing along the same lines of ‘directive practice’ will continue to reduce nurse autonomy and drive down job dissatisfaction within the workplace. Examining and de-implementing low-value care that is not showing to make a difference, will allow nurses more time to practise those strategies that are effective.

A revolution in the way we do patient safety is needed. The creation of positive safety cultures that are evidence-based and enhance both clinician safety practices and engagement is needed. Reductive patient safety-focused solely on hospital-acquired complications and audits have left clinicians disillusioned and patients continuing to suffer harm. Ultimately, we must listen to nurses on how patient safety can be improved, rather than a paternalistic ‘top down’ approach that adds to the workforce burden.

Disclosure statement

All authors declare that there are no conflicts of interest with this editorial manuscript submission.