Feature
NURSING MANAGEMENTApril 2009 | Volume 16 | Number 134
References
by the IHI campaign in the Us, by the World
Health Organization in relation to safer surgery,
and more recently as part of the Safer Patients
Initiative in the UK.
service and safety improvements are not
undertaken on the same scientific basis as
randomised controlled trials but a system
of improvement in health care, in which small changes
are tested and refined before being applied to practice
on a larger scale, is being developed.
the basic method used in this system, the Plan,
Do, study, act cycle (Langley et al 1996), has been
integral to much of the work led by the NHs Institute
for Innovation and Improvement.
Other work in improving the understanding
and knowledge of patient safety involves the study
of `human factors', or `non-technical skills', which
concern how people interact and engage with one
another and their environments, and therefore the
likelihood that they will make errors.
In the airline industry, for example, a wide range
of human factor issues is considered in the training
programmes of pilots and other staff.
It is generally recognised in such high-risk
industries that non-technical skills, including
situational awareness and communication, are often
as important as technical knowledge and competence
(Flin et al 2008).
Communication problems are cited by
van Beuzekom et al (2007) as a common cause
of adverse incidents in health care. It follows
that, if there is to be a substantial reduction in
the incidence of adverse events, improvements
in patient safety, and in staff knowledge and
capability, are key requirements at all levels of
every healthcare profession.
Conclusion
Nurses are central to creating the contexts in
which health care is delivered, and can be the
most passionate advocates of patient safety. Nurse
leaders are therefore in strong positions to influence
the patient safety agenda by leading by example and
by inspiring their colleagues.
the Patient Safety First Campaign attempts
to guide staff in improving patient safety, but
hospitals and healthcare organisations must find
the appropriate ideas and develop the will to deliver
such improvement.
Implications for practice
Nurse leaders have a responsibility to set patient
safety aims, and to ensure that they can build
the will and capability to improve practice as
part of a system-wide campaign to reduce levels
of patient harm.
Further reading
To access the Patient Safety First Campaign
website, go to www.patientsafetyfirst.nhs.uk
For details of the IHI's Global Trigger Tool, go to
www.ihi.org/IHI/Topics/PatientSafety
Mike Williams is an
NHS senior research
fellow at the University
of Exeter Business School
Jane Reid is a senior
academic at the school
of health and social care
at Bournemouth University,
and immediate past president
of the Associaiton for
Perioperative Practice
Classen DC, Lloyd RC, Provost L et al (2008) Development
and evaluation of the Institute for Healthcare Improvement
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Flin R, O'Connor P, Crichton M (2008) Safety at the Sharp End.
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