Five System Barriers to Achieving Ultrasafe Health Care

Abstract

Although debate continues over estimates of the amount of preventable medical harm that occurs in health care, there seems to be a consensus that health care is not as safe and reliable as it might be. It is often assumed that copying and adapting the success stories of nonmedical industries, such as civil aviation and nuclear power, will make medicine as safe as these industries. However, the solution is not that simple. This article explains why a benchmarking approach to safety in high-risk industries is needed to help translate lessons so that they are usable and long lasting in health care. The most important difference among industries lies not so much in the pertinent safety toolkit, which is similar for most industries, but in an industry's willingness to abandon historical and cultural precedents and beliefs that are linked to performance and autonomy, in a constant drive toward a culture of safety. Five successive systemic barriers currently prevent health care from becoming an ultrasafe industrial system: the need to limit the discretion of workers, the need to reduce worker autonomy, the need to make the transition from a craftsmanship mindset to that of equivalent actors, the need for system-level (senior leadership) arbitration to optimize safety strategies, and the need for simplification. Finally, health care must overcome 3 unique problems: a wide range of risk among medical specialties, difficulty in defining medical error, and various structural constraints (such as public demand, teaching role, and chronic shortage of staff). Without such a framework to guide development, ongoing efforts to improve safety by adopting the safety strategies of other industries may yield reduced dividends. Rapid progress is possible only if the health care industry is willing to address these structural constraints needed to overcome the 5 barriers to ultrasafe performance.

Measuring human-error probabilities in drug preparation: a pilot simulation study

“…With regard to operators, methods for improving arithmetic skills could be tested [20], and professionals could be licensed and relicensed [32] to carry out specific tasks within the medication process. This would help implement the principle of equivalent operators, one of the pillars of safe systems as put forward by Amalberti et al [33].…”

Applying Safety Science to Genetically Modified Agriculture

“…That arrangement makes for the historical "defense in depth" of the nuclear industry. The "modern" defense-in-depth concept has profited from two sources at least: (1) The results of the human factors research on categories of errors and mishaps, which led to more effective error prevention and risk mitigation strategies (Reason, 1990;Reason, 1997;Amalberti, 2005); (2) The results of organizational studies attempting to better understand the social production of safety during "normal" operations (Rochlin, La Porte, & Roberts, 1987;Weick, 1987;La Porte & Consolini, 1991;Rochlin, 1998;Weick & Roberts, 1993;, Bourrier, 2002Perin, 2005), along with important work done on major accidents (Vaughan, 1996;Starbuck & Farjoun, 2005), which revealed the mechanisms of what Vaughan has labeled "the normalization of deviance," or Snook, "the drift into failure" (Snook, 2000).…”

“…It is of interest to note in passing that the medical field is also interested in this line of thinking, and is struggling to put in place system barriers, capable of reducing preventable errors (Amalberti et al, 2005;Carroll & Rudolph, 2006). This description is not aimed at suggesting that those barriers are sufficient to guarantee operational safety.…”

“…Historically, safety science has dealt with high-risk technological enterprises (nuclear power industry, chemical industry, aviation industry) and more recently with medical practices (Vincent & De Mol, 2000;Amalberti, Auroy, & Berwick, 2005). Safety science has expanded over the years.…”

Effect of venepuncture process design on efficiency and failure rates: A simulation model study for secondary care

“…These techniques have been widely applied for setting safety and reliability standards in system design, operation and maintenance (Amalberti et al, 2005). One of the traditional methods used in industry is the approach of probabilistic risk assessment, originally developed for improving safety of nuclear plants (Vesely, 1970), and later applied in many different settings ranging from aerospace (Frank, 1995) to process industry (Kelly and Lees, 1986).…”