The systems approach at the sharp end

Abstract

A systems-based approach to patient safety has been widely accepted and advocated. Despite this, and a renewed emphasis on organisational learning in improving the safety of patients, many patients still suffer unintended harm during their care. This paper reviews the central theoretical themes of a systems-based approach and raises four key questions relating for clinicians working at the 'sharp end': how can clinical teams best apply a systems approach to patient safety, how can patient safety move from a focus on past harm to a proactive approach, how can we avoid a corrosive culture of blame, and what should our response at the sharp end be to seemingly unsolvable problems?

Entwicklung des klinischen Risikomanagements in deutschen Krankenhäusern

“…Noch wichtiger ist es jedoch, Ärzt:innen und Pflegekräften feste Zeitkontingente für das kRM zur Verfügung zu stellen (Bottom-up-Ansatz). Diese Berufsgruppen sind es, die am "sharp end of patient care", wie es Cross et al [41] kürzlich noch einmal formuliert haben, klinisches Risikomanagement betreiben. Sie müssen Fähigkeiten, Gelegenheit und Motivation haben, den Risikomanagementprozess in ihren Krankenhäusern umzusetzen.…”

“…Diese Berufsgruppen sind es, die am „sharp end of patient care“, wie es Cross et al. [ 41 ] kürzlich noch einmal formuliert haben, klinisches Risikomanagement betreiben. Sie müssen Fähigkeiten, Gelegenheit und Motivation haben, den Risikomanagementprozess in ihren Krankenhäusern umzusetzen.…”

Moving towards evidence-based care system design

“…From a patient safety perspective Steve Cross in The systems approach at the sharp end reminds us that 'the way in which a system operates is a major determinant of risk and risk can lead to harm' . 1 We not only need to respond to harm or potential harm with a systems understanding, but also should be designing in lower risk, and therefore less potential of harm. This review is pertinent in the light of recent high profile cases, but also highlights the need for considerable training of professionals in a systems approach to patient safety.…”

Hospital Admission Less than 30 Days after Chemotherapy: Results from a Chemotherapy-Specific Morbidity and Mortality Conference in Gynecologic Oncology

“…These non-punitive conferences involve the analysis of complications using peer review in an attempt to identify systems-based approaches to improve patient care. These forums have been shown to promote disclosure of medical errors [1] [2] [3], to improve patient safety [4] [5] and to play a key role in encouraging a systems-based approach to identify causes of adverse events and potential solutions [6] [7]. While these conferences have traditionally been used in surgical specialties [5], they have been adopted widely by a range of specialties, including internal medicine [1] [8] [9], emergency medicine [10], rehabilitation medicine [11], psychiatry [12] and intensive care [4].…”