Making Health Care Safer – More Plenary Talks

I really liked Denis Fischbacher-Smith’s talk. He talked about the report Organisation with a Memory which he worked on. This was based on the premise that organisations should learn from adverse effects in order to prevent future systems failures. 

He identified three main obstacles to learning 

1. organisations driven by short term imperatives
2. high management turnover and
3. involvement of politicians.

He stressed the difference between passive (lessons are identified but not put in practice) and active learning (lessons become embedded in organisational culture and practices) but also pointed out the communication problems across disciplines and between medical and management functions. Other points he touched upon where the importance of culture and the problem that organisations tend to manage what they can measure. All in all his talk was fairly pessimistic (some might say realistic) about organisational learning. But perhaps this is just another example that we really need new ideas and approaches in health care which are compatible with the existing culture and hopefully can shift it towards being more receptive to learning in the long run.

The first talk on day two brought the focus back on patient safety. Teun Zuiderent-Jerak who looked argued that while safety is a system property, there are several ways a problem can be framed and approaches. He used medication safety as an example, where the classical approach is to control medication behaviour and report errors, while an alternative approach is to see errors and safety as synonyms. The first approach would seek to standardize dispensation while the second one focuses on fostering resilience. Such a shift from control to delegation would have impacts on multiple levels – and would raise very different questions when it comes to spreading and sustaining change than the first approach of standardization.

The last plenary talk was by Justin Waring who first summarized where he sees the field of patient safety. He felt that the scale of the problem, its sources and potential solutions have been well researched in the past years. But there are still gaps that future research will have to address. To do so, he identified three critical perspectives: knowledge (which seems to be sticky when it would need to be slippery and vice versa), cultures (how ideas are lives and breathed) and power and organization (resistance to change and unintended consequences). 

He went on to identify four concrete gaps: 

1. Sources of safety
2. Roles of professional practice networks
3. Role of emotion and
4. Spaces between care processes.

Slides for many of the plenary (and parallel sessions) can be found here:

http://www.sdhi.ac.uk/pastconferences.htm