‘Knowledge is the driver of change and will make a difference': a blog from Peter Lachman

Summary

Peter Lachman explains why safety must be embedded into what we do every day, not what we do only after harm has occurred, and why we need to constantly ask ourselves “what do we need to do to be safe?” His new book, Oxford University Press Handbook of Patient Safety, translates the complex patient safety theories into actions that frontline staff can take to be safe. 

Content

It is 22 years since the publication of To Err is Human and An Organisation with a Memory. Patient Safety has become a priority worldwide with the passing of the WHO Global Action Plan on Patient Safety. Almost every country has a plan or set of interventions to decrease harm and make healthcare safer. And the development of the science of patient safety has been exponential with increasing evidence of what is required to be safe. We now know what we need to do to prevent harm.

In the report led by Sir Liam Donaldson it was stated that four actions were needed to improve safety in the NHS:

• unified reporting
• an open culture
• mechanisms for change
• a systems approach to solving the challenges of patient safety.

Twenty-two years on this challenge remains only partially fulfilled. As is reported in the recent Patient Safety Learning's Mind the implementation gap - The persistence of avoidable harm in the NHS, there is a major problem of taking the lessons from incidents and implementing them at scale so that processes can be changed. The report highlighted four themes, focusing mainly on the lack of a systems approach to safety, learning, oversight monitoring and evaluation, and a lack of leadership.

If we are to be safe in the future there must be a fundamental change to the way we think about safety, and the need to incorporate both improvement and implementation science in addressing the implementation gap. There are many reasons for the gap in applying what we know to what we do. This is not uncommon in healthcare where new knowledge takes time to percolate to frontline staff and applies to clinical theory as well as to patient safety theories and methods. So while we may state that we need a systems approach and leadership, we cannot expect frontline staff to be safe if they do not have easy access to the latest theories and methods on patient safety.

I believe that to make a difference we need to equip every healthcare worker with the knowledge and skills to be safe. From that frontline revolution we can then look at having a safer NHS in which safety is what we do every day, not what we do only after harm has occurred. This includes learning from everyday practice and constantly asking ourselves “what do we need to do to be safe?”

The Oxford University Press Handbook of Patient Safety aims to bridge the knowledge gap so that the  implementation gap can be narrowed and eventually closed. The book has been written by a combination of experts in the field of patient safety science and frontline staff, i.e. people who practice safety every day and know what it takes to be safe. The book translates the complex patient safety theories into actions that frontline staff can take to be safe. We hope that the book will make a difference in changing the paradigm and that it becomes the daily companion of every healthcare professional in the NHS.

Knowledge is the driver of change and will make a difference. 

The Oxford Professional Practice: Handbook of Patient Safety is available at the discounted price here.

About the Author

Peter is Lead of the Faculty Quality Improvement Programme, Royal College of Physicians of Ireland, and Lead Editor of the OUP Handbook of Patient Safety.