Distractions are common in anaesthetic practice and managing them is a key professional skill which appears to be part of the tacit knowledge of anaesthesia. Anaesthetists should also bear in mind that the potential for distraction is mutual and reciprocal and their actions can also threaten safety by interrupting other theatre staff.
Several psychological factors involved in checking and its relevance to healthcare and patient safety are identified. Additionally, recommendations for further research are indicated.
Current patient safety orthodoxy in the United Kingdom and beyond has tended to treat risk as something that should be assessed and estimated quantitatively. While this offers benefits to research and practice, there are added benefits from paying closer scrutiny to the underlying causes that influence such adverse events in healthcare. In this article, risk is seen as something subjective, or rather as part of the "lived experiences" of healthcare professionals. Results from this study indicate that the vast majority of healthcare professionals we interviewed understand risk as something intrinsic to healthcare; another variable one needs to prepare for. Risks were generally described in terms of acceptable versus unacceptable and avoidable versus unavoidable. In terms of identifying and dealing with risk, we found indications that the decision-making processes healthcare professionals use vary according to their training and experience. We suggest that the further examination of the apparent differences that exist in the perceptual awareness of risk can advance our knowledge on the possible impact they could have upon patient safety in the wider spectrum.
RationaleRecent reports indicate that approximately 10% of in-patients in UK hospitals are involved in an adverse event (these reports also state that 50% of these events are preventable). This is indeed a worrying finding, and indicates the need to look at how these incidents are handled or indeed, what is done to minimize their occurrence. The Department of Health, via the National Patient Safety Agency (NPSA) published a guide which is aimed at encouraging accurate reporting, learning from past events and changing the attitudes of key stakeholders (healthcare managers, frontline staf etc) towards risk taking and risk management. Aims and objectives Our aim was to compare informally-learned and used risk assessment strategies volunteered by staff with the 'how to do it' guide published by the NPSA. We have compared each step of the NPSA guide with our empirical data relating to that activity. Methods We interviewed forty-eight healthcare professionals (doctors from several specialties; nurses from a variety of settings; and an array of allied healthcare professionals). We used semi-structured interviews in order to discuss participants' views on their everyday working life, working relationships and patient safety. Results Our results indicate that healthcare professionals develop their own unique way to approach the issue of patient safety and risk, based on their professional raining, seniority and role within the hospital. They did share the conviction that frontline and support staff need to have immediate and easy access to information about past adverse events. They see this as a powerful tool in minimizing the reoccurrence of the same errors/problems, as well as a vehicle to improve staff morale by feeling valued and having their opinion heard. Conclusions We believe that patient safety and welfare can benefit from the adoption of a more flexible and person-centred approach to how risk assessments are carried out. Enriching formal guidelines such as the 'Risk Assessment made easy' document with successful techniques and strategies which healthcare staff have informally developed has the potential to not only improve patient safety (since it will be based on the accumulated experience and knowledge of such staff) but also foster higher levels of self esteem amongst healthcare professionals. bs_bs_banner ISSN 1365-2753
Journal of Evaluation in Clinical Practice
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