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Disturbing the Doxa of Patient Safety Comment on "False Dawns and New Horizons in Patient Safety Research and Practice".

ABSTRACT: In a recent edition of this journal, Mannion and Braithwaite provide a succinct analysis of the emergence, and ultimately limited impact, of what they term the current 'Safety I' movement in healthcare. They describe the arc of this field from denial, through engagement via mechanisms and approaches imported from other industries, to the current situation where, despite 'best efforts,' error rates remain stubbornly recalcitrant. In examining the failure of system-wide efforts to produce sustained reductions in errors and adverse events, that article exposes the doxa, or what Bourdieu calls 'the taken for granted' which is central to this latest wave of patient safety movement. In this commentary, I would like to take focus on two key elements of Mannion and Braithwaite's argument: that harm is caused by misguided but otherwise well-intentioned actions and the 'embracing' of patient safety. I then conclude by briefly considering the implications of these for Safety II, particularly as envisaged by the authors as an evolutionary, and therefore linear progression, from Safety I.

SUBMITTER: Travaglia J

PROVIDER: S-EPMC6186486 | biostudies-literature | 2018 Sep

REPOSITORIES: biostudies-literature

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Disturbing the Doxa of Patient Safety Comment on "False Dawns and New Horizons in Patient Safety Research and Practice".

Travaglia Joanne J

International journal of health policy and management 20180901 9

In a recent edition of this journal, Mannion and Braithwaite provide a succinct analysis of the emergence, and ultimately limited impact, of what they term the current 'Safety I' movement in healthcare. They describe the arc of this field from denial, through engagement via mechanisms and approaches imported from other industries, to the current situation where, despite 'best efforts,' error rates remain stubbornly recalcitrant. In examining the failure of system-wide efforts to produce sustaine ...[more]

PMID: 30316235

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Project description:AIMS AND OBJECTIVES:To test the method of self- and external assessment as a feedback system to decrease illegibility and incorrectness of handwritten prescriptions and to reduce additional workload for nursing staff. BACKGROUND:Illegibility and incorrectness of handwritten prescriptions occur very often and are the most crucial factors affecting patient safety. DESIGN:Self- versus external assessment using a 15 items checklist. METHODS:Nurses randomly selected five fever charts of their wards. Each fever chart was self- as well as externally assessed. Nurses and doctors took part in the self-assessment, and the external assessment was performed by external experts. According to a monitor suspension system, assessment results were considered "green," "yellow" or "red." After the first assessment and issuing feedback of the results "red" scored wards by the external assessment, additional trainings were performed. Thereafter, a second assessment was performed to rate eligibility and completeness of prescriptions. The research and reporting methodology followed squire 2.0. RESULTS:In total, 580 fever charts were self- as well as externally assessed (290 in each of the two assessment periods). Out of the 58 participating wards, 31 were surgical and 27 were non-surgical wards. Averaging over all checklist items, surgical and non-surgical wards improved only slightly over time. Linear regression models for ward means showed that there were significant improvements over time for non-surgical wards. CONCLUSIONS:This method directly involves those who commit errors and stimulate learning from errors. The approach of self- and external assessment was a useful instrument to detect inadequate prescriptions and to monitor improvements. RELEVANCE TO CLINICAL PRACTICE:Significant improvements were achieved regarding correctness and legibility of handwritten prescription and helped to decrease additional workload for nursing staff and thereby enhanced patient safety.

Dataset Information

Disturbing the Doxa of Patient Safety Comment on "False Dawns and New Horizons in Patient Safety Research and Practice".

Publications

Disturbing the Doxa of Patient Safety Comment on "False Dawns and New Horizons in Patient Safety Research and Practice".

Similar Datasets

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