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Reclaiming the systems approach to paediatric safety
  1. Ronny Cheung1,
  2. Damian Roland2,3,
  3. Peter Lachman4
  1. 1General Paediatrics, Evelina London Children’s Hospital, London, UK
  2. 2Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children’s Emergency, Leicester Royal Infirmary, Leicester, UK
  3. 3SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK
  4. 4International Society for Quality in Health Care (ISQua), Dublin, Ireland
  1. Correspondence to Dr Ronny Cheung, General Paediatrics, Guys and St Thomas' NHS Trust, London SE1 7EH, UK; ronny.cheung{at}gstt.nhs.uk

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Introduction

Prior to the emergence of the patient safety movement as a distinct science, it was assumed that the safety of patients was an outcome of good professional acumen, and that if healthcare providers could individually perform well then their patients would remain safe at all times.

It is now 20 years since the publication of To Err is Human,1 the first major review of healthcare safety in the USA. In the UK, the publication Organisation with a Memory2 in 2000 supported the view that patient safety required a wider system approach. Both documents reframed safety and error in healthcare as an organisational or system issue rather than one of individual error, whether of omission or of commission. Over the past 20 years, there has been major progress in the understanding of patient safety and the complexity of the systems involved in providing healthcare. In a recent review of the state of patient safety in 2018, Bates and Singh3 conclude that ‘Highly effective interventions have since been developed and adopted for hospital-acquired infections and medication safety, although the impact of these interventions varies because of their inconsistent implementation and practice’.

Within paediatrics, the National Patient Safety Agency made the first attempt in the UK to detail the extent of healthcare-derived harm among children.4 The problems identified remain a challenge—namely communication, deterioration, delayed or missed diagnosis, infections and medication harm. This is despite well-tested theories and interventions being available for many of these. In this paper, we explore the theories of patient safety and provide principles to tackle the challenge ahead.

The evolution of patient safety theories

The original approach to patient safety was essentially limited to risk management and review of adverse events. This included the introduction of root cause analysis and failure mode effects analysis, which aimed to understand the …

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