Structures, processes and outcomes for better or worse: Personal responsibility in patient safe care

Summary

Expanding on his previous commentary 'What does all this safety stuff have to do with me', Dan Cohen, Patient Safety Learning's Trustee and former Chief Medical Officer at DATIX, has written this article for the hub on personal responsibility in patient safe care.

Content

In this article, Dan looks back at the Donabedian Model, a framework for measuring healthcare quality, and suggests why this might be an over simplification and why we must also look at human factors when we think about patient safety. We are humans and we can, do and will make mistakes, so we have a personal responsibility to acknowledge and address this as a contributing factor for patient safety incidents and harm. 

How do we begin to address our individual responsibilities? How can each of us reduce the personal risks we pose for our patients? How do we begin to address the moral imperative to recognise and then overcome any professional complacency that may interfere with our performance? 

Dan believes by enhancing human performance within healthcare settings this will serve as the ultimate key to improving quality and safety. Recognition by clinicians of their own tendencies toward complacency and their own vulnerabilities toward making mistakes is to encompass a mandate for personal professional commitment and improvement.  

If patients are harmed on the frontlines in healthcare settings, then it is on the frontlines that many of the solutions can be found and safety improvements nurtured. First recognising, and then modulating, the human factors liabilities that exist on the frontlines and overcoming the challenges of professional complacency will be necessary steppingstones towards sustained improvements in providing patient safe care.  

Clinicians, managers and leaders need to work collaboratively to understand and overcome the challenges that human factors pose when addressing individual performance.

Further reading on the hub from Dan:

• Clarity and the Art of Communication for Patient Safety
• Late night reflections on patient safety: commentaries from the frontline (2014)
• Patient safe care as a moral imperative: The mandate of medical ethics
• Diagnostic errors and delays: why quality investigations are key
• Patient Safety Spotlight Interview with Dr Dan Cohen, Patient Safety Learning Trustee
• What does all this safety stuff have to do with me? How one professional’s arrogance led to new insights
• Interview with Dr Dan Cohen on human performance