How safe are clinical systems?

Th is study was commissioned by the Health Foundation to examine the extent, type and causes of failures in reliability in different healthcare systems: failures which have the potential to create risk or cause patient harm

How safe are clinical systems? Primary research into the reliability of systems within seven NHS organisations

The knowledge that poor systems can cause harm is not new, but the size of this problem has not been established systematically. This report provides groundbreaking evidence of the extent to which important clinical systems and processes fail, and the potential these failings have to harm patients. This study forms part of the Health Foundation’s work to help healthcare organisations improve the quality of services they offer. Our Safer Patients Initiative has highlighted the need to take a clinical systems approach to improving safety, since it is failings in these systems that often contribute to breakdowns in patient safety

The Social Organization of Interactions Involving People with Aphasia

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How safe are clinical systems? Primary research into the reliability of systems within seven NHS organisations

The knowledge that poor systems can cause harm is not new, but the size of this problem has not been established systematically. This report provides groundbreaking evidence of the extent to which important clinical systems and processes fail, and the potential these failings have to harm patients. This study forms part of the Health Foundation’s work to help healthcare organisations improve the quality of services they offer. Our Safer Patients Initiative has highlighted the need to take a clinical systems approach to improving safety, since it is failings in these systems that often contribute to breakdowns in patient safety

Evidence : how safe are clinical systems?

‘Rather than being the instigators of an accident, operators tend to be the inheritors of system defects …their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking’ (James Reason, 1990) This study was commissioned by the Health Foundation as part of its work to examine how systems reliability affects patient safety, and how this can be improved. The purpose of the research was to describe the nature, type, extent and variation in the reliability of five healthcare systems that have the potential to cause harm to patients in UK hospitals. These are: the availability of clinical information in outpatient clinics, prescribing for inpatients on hospital wards, clinical handover between doctors, equipment availability in the operating theatre, and systems for inserting intravenous lines. Seven hospitals from across the UK participated in the research. Each clinical system was studied in three hospital organisations. The research began in January 2009 and, including the time taken to gain ethical approval, was completed within a year