Patient Safety [Paperback]

This is a superb book. I can strongly recommend it to all doctors, to medical students, to other clinical staff and to managers who have to try and make sense of the chaotic complexity of healthcare. Your practice of medicine will be safer and more effective as a result of reading the ideas contained in this book, and even more so if shared with colleagues, discussed and selectively and sensitively adopted. If you will accept this summary then buy this book now and get on with reading it.

That's a strong opening and I had better now justify it.

Reading this book felt like I was reading the book I should have read alongside basic medical textbooks such as Davidson's Principles and Practice of Medicine: With STUDENT CONSULT Online Access (Principles & Practice of Medicine (Davidson's))or Kumar and Clark Clinical Medicine. Sadly it was not written when I was a student (I graduated 1989) One of the author's key ideas is that doctors should devote as much energy to understanding the systems within which they work as they do to learning to understand the various biological systems they will be treating in their patients, and the longer I go on in medicine the more I am coming to agree with this perspective.

The ideas in this book have always been present within medicine, but they have developed and become a formal, organised and significant body of knowledge over the last twenty years or so. When I was a student I remember our clinical sub dean explaining to us that medicine was a very individualistic profession, and that success or failure was very much a reflection on us personally. Problems were seen as being caused by character flaws and ignorance, not as events that would happen every so often, and which would arise from a complex mix of personal factors, the system, and the patient and their diseases and our treatments of them. The subject of error was always a worry, but rarely seen positively, or as Kathryn Schulz describes inBeing Wrong: Adventures in the Margin of Erroran opportunity for learning.

The NHS keeps its doctors busy, and gives them relatively (and sometimes absolutely) little time for reflection on their work. Most doctors are busy getting on with their work, rather than thinking about exactly what their work should be, and about how it should be carried out safely, effectively and humanely. The pleas have gone out for "clinical Engagement" but most doctors feel they are already fully engaged with their work- and that if they are any good at their job it is mostly despite the NHS rather than because of it.

Professor Vincent is an internationally respected expert on patient safety and in this book he defines the problem (many patients are harmed by the healthcare system) and then describes well the various ways of looking at this problem, analysing it, and trying to improve the situation. He does this gradually, and pays attention to the tragedy of avoidable medical harm and then to the analysis of the structures, processes and outcomes of care that give rise to these avoidable harms. He pays attention to events at the level of individual doctors, nurses and patients and at the level of the systematic factors that lead to healthcare systems harbouring these risks of harm. He emphasises that errors should be understood at many levels- the patient, the individual clinician, the system and its culture. He castigates the rush to blame and shame individuals seen in response to some events, as opposed to nuanced investigations that look at errors at many levels. That said sometimes individuals are personally culpable, but more often the system has set up the individual for a fall.

This book is a superb summary of and introduction to safety issues in healthcare. The author's expertise is demonstrated throughout, and his examples are drawn from UK, American, European healthcare systems, with appropriate comparison across to other industries where they are useful. He is superb at describing the strengths and weakness of the various measurements that can be made, and at showing whether and when comparisons with other industries and occupations are accurate or not.

This book has significant knowledge within it that I think all practising doctors and nurses, and most healthcare managers should know and understand. Medical students should read it as preparation, but will not realise how much wisdom it contains till they have been practising for a few years. The knowledge in this book will add to your speciality knowledge, and allow you to use that more effectively and safely to benefit patients.

The book is thorough enough to be useful, without being too long. It is well written and well referenced. It is well structured and easy to follow and understand. Professor Vincent has done clinicians, managers and their patients a great service by bringing this knowledge together into an accessible and usable format.

Indeed if the ideas in this book were implemented, and if we concentrated on ensuring the safe flow of patients around the system, e.g as describedSystems Thinking in the Public Sector: The Failure of the Reform Regime.... and a Manifesto for a Better Way by John Seddon rather than on the atomised unit costs of Refusing Treatment: The NHS and market-based reformmarket transactions then it would make a better white paper for the NHS than the current one.

Lots of good ideas in this book for doctors, nurses, and the managers. I recommend it strongly to my colleagues in the UK NHS, and in other healthcare systems worldwide.

Whilst this revision of a healthcare "classic" does a good job of re-emphasising the nature of patient safety challenge in healthcare as well as providing both a valuable historical analysis and solid perspective on the practical approaches to building capability to implement safety improvements, it fails to fully grasp the nettle of the future challenges of patient safety in the 21st Century.

The final chapters provide a tantalising glimpse of the author's perspective on the contemporary debate in this field, particularly the focus on human factors and safer clinical systems; and the emerging evaluation and critique of the dominant narratives in the patient safety world, however for the seasoned practitioner it will already feel out of date.

Despite this minor criticism, "Patient Safety" will undoubtedly remain a seminal text for students and practitioners alike for years to come.

Recommended for all in health care because safety has always been an issue. Hippocrates declared `abstain from harming or wronging any man'. Recent shortcomings in the standard of nursing care with elderly patients in the National Health Service have exposed serious problems and a lack of management leadership and support. Patient safety potentially touches everyone.
Latrogenic disease is on an uptrend - long hospital admissions and complex procedures both lead to complications. The Bristol paediatric heart surgery scandal broke in 1995 and caused a public outcry, 29 children died and two doctors were struck off the medical register. The official enquiry in 1998 cost £14 million: the systematic analysis of failings showed a range of environmental and cultural factors leading to nearly 200 recommendations.
Now incidents are more frequently recognised. This book covers modern approaches such as the UK National Patient Safety Agency as well as other initiatives from the USA and Sweden.
Patient safety is not just about avoiding harm. It includes steps to prevent identifiable risks and improve the overall quality of care. Harm may be due to not providing effective treatment or insufficient monitoring e.g. of blood glucose in diabetics. Health care problems may arise from many sources: medication errors can result from poor handwriting, wrong drug and wrong route. The elderly are at especial risk due to the numbers of different medications and the increased potential for confusion. Neonates are very vulnerable and drug doses are critical. Doctors lacking relevant training or experience may misinterpret vital clinical signs.
Reporting and learning systems are essential so we can learn from mistakes. The UK `Yellow Card' system was set up in 1964 after the thalidomide tragedy. Errors are often due to system failure rather than individual blame. Patients deserve better but the repercussions on medical personnel can be profound leading to anxiety and depression. Poor performance leads to a deteriorating spiral and the risk of professional `burn-out'. Vincent describes practical strategies for coping with error and harm. Errors needs to be recognised and openly acknowledged. Proper support for the patient and relatives and also of staff involved.
Evidence based medicine shows the importance of preventing venous thromboembolism. Without prophylaxis the incidence of such clots is 20% of all major surgical procedures and 50% of orthopaedic procedures. This is not just a safety issue - appropriate care is also cost effective. Vincent shows how process management can lead to incremental improvement, reducing complexity, improving efficiency and leading to fewer potential mistakes.
The sections on `designing out' hospital acquired infection are helpful for infection control staff and architects. Prescribers and pharmacists benefit from seeing how information technology can reduce medication errors. Bar coding minimises lab errors and reduces the risks of blood transfusion. Electronic medical records remain largely a fantasy in hospitals but computers should help analyse data to improve outcomes and safety. Managers need to know how to create `high reliability organisations'.

Dr Robert Harvey, Consultant Ophthalmologist, Paisley.