Resilient health care: re-conceptualising patient safety | Event | AIHI - Australian Institute of Health Innovation
A captivating presentation by Professor Jeffrey Braithwaite on Resilient health care: re-conceptualising patient safety
Resilient health care: re-conceptualising patient safety
It is widely believed that to improve patient safety we need to reduce medical errors, but it is not always clear how to do this effectively and efficiently. Over the last two decades health systems have adopted techniques including teamwork training,[2, 3] checklists and standardisation from other industries, seeking high levels of reliability. While these interventions have shown promise in reducing some types of errors in specific circumstances,[5, 6, 7, 8] they are not always applicable across health care as a whole, and the impact has sometimes been disappointing, with spread and sustainability not well demonstrated. Research has shown that large, system-wide interventions, such as the introduction of Medical Emergency Teams to identify and manage deteriorating patients,[9, 10] have met with some–but often variable–success. This presentation will examine what the current evidence tells us about how to reduce medical errors, what techniques work, and where. We will examine two different types of thinking about patient safety–Safety-I and Safety-II approaches–that help us understand how best to manage errors in complex health care environments. We review traditional techniques such as the Swiss Cheese Model,13] and present newer ideas, such as the Resilience Analysis Grid, to enhance our understanding of how patient safety can be improved. The Safety-II approach argues: instead of focusing on things going wrong, we must also direct our attention to things going right. We will discuss this new paradigm, and its potential for widespread application.
Professor Jeffrey Braithwaite, BA, MIR (Hons), MBA, DipLR, PhD, FAIM, FCHSM, FFPHRCP (UK) is Foundation Director, Australian Institute of Health Innovation, Director, Centre for Healthcare Resilience and Implementation Science and Professor of Health Systems Research, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia. His research examines the changing nature of health systems, particularly patient safety, standards and accreditation, leadership and management, the structure and culture of organisations and their network characteristics, attracting funding of more than AUD$59 million.
Professor Braithwaite has published extensively (more than 600 total publications) and he has presented at international and national conferences on more than 780 occasions, including over 75 keynote addresses. His research appears in journals such as British Medical Journal, The Lancet, Social Science & Medicine, BMJ Quality and Safety, International Journal of Quality in Health Care, Journal of Managerial Psychology, Journal of the American Medical Informatics Association, and many other prestigious journals. Professor Braithwaite has received numerous national and international awards for his teaching and research. Further details are available at his Wikipedia entry: http://en.wikipedia.org/wiki/Jeffrey_Braithwaite.
He has conducted a great deal of work over two decades on clinical and organizational performance, health systems improvement and patient safety. Professor Braithwaite was author of a major study into health care inquiries, Patient safety: a comparative analysis of eight inquiries in six countries, UNSW, 2006 and another on the appropriateness of care in Australia (BMJ Open, 2012 and Medical Journal of Australia, 2012).
Professor Braithwaite recently co-edited a book with Professors Erik Hollnagel in Denmark and Bob Wears in the United States (Resilient Health Care, Ashgate, 2013), which proposes new models for tackling patient safety in acute settings and a second book in the series, The Resilience of Everyday Clinical Work, was published in 2015. His book on health reform in 30 countries with Professors Julie Johnson in the US, Yukihiro Matsuyama in Japan and Russell Mannion in the UK was published in 2015. Another, on new sociological perspectives on patient safety with Professors Davina Allen at Cardiff University, Jane Sandall at King’s College, London and Justin Waring at Nottingham University, will be published in 2016.
Date: 20 August 2015
Time: 12pm - 1pm
Venue: Level 1, 75 Talavera Road, Macquarie University
1. Braithwaite J, Coiera E. Beyond patient safety flatland. Journal of the Royal Society of Medicine 2010, 103: 219-225.
2. Buljac-Samardzic M, Dekker-van Doorn C, van Wijngaarden J, van Wijk K: Interventions to improve team effectiveness: a systematic review. Health Policy 2009, 94(3): 183-195.
3. Thomas E, Williams A, Reichman E, Lasky R, Crandell S, Taggart W: Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. Pediatrics 2010, 125:539.
4. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine 2009, 360(5):491-99.
5. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G: An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine 2006, 355:2725-2732.
6. Salas E, DiazGranados D, Klein C, Burke CS, Stagl KC, Goodwin GF, Halpin SM: Does team training improve team performance? A meta-analysis. Human Factors: The Journal of the Human Factors and Ergonomics Society. 2008, 50:903-933.
7. Gawande AA, Zinner MJ, Studdert DM, Brennan TA: Analysis of errors reported by surgeons at three teaching hospitals. Surgery 2003, 133:614-621.
8. Clay-Williams R, McIntosh C, Kerridge R, Braithwaite J: Classroom and simulation team training: a randomised controlled trial. International Journal for Quality in Health Care 2013, 25:doi: 10.1093/intqhc/mzt1027.
9. Hillman K, et.al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. The Lancet 2005, 365:2091-2097.
10. Hughes C, Pain C, Braithwaite J, Hillman K. 'Between the flags': implementing a rapid response system at scale 2014 in press, BMJ Quality and Safety, Online First: 16 April 2014.
11. Hollnagel E, Braithwaite J, Wears R (eds). Resilient health care. Surrey, UK: Ashgate Publishing Limited, 2013.
12. Braithwaite J, Clay-Williams R, Nugus P, Plumb J: Health care as a complex adaptive system. In: Hollnagel E, Braithwaite J, Wears R (eds). Resilient health care. Surrey, UK: Ashgate Publishing Limited, 2013.
13. Reason J: Human error: models and management. BMJ 2000, 320:768-770.
14. Hollnagel E, Pariès J, Woods DD, Wreathall J: Resilience engineering in practice: a guidebook. Surrey, UK: Ashgate Publishing Limited; 2011.