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Risk, Safety and Clinical PracticeHealth care through the lens of risk$
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Bob Heyman, Andy Alaszewski, Monica Shaw, and Mike Titterton

Print publication date: 2009

Print ISBN-13: 9780198569008

Published to Oxford Scholarship Online: February 2010

DOI: 10.1093/acprof:oso/9780198569008.001.0001

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Health risk and the patient safety agenda

Health risk and the patient safety agenda

Chapter:
(p.195) Chapter 9 Health risk and the patient safety agenda
Source:
Risk, Safety and Clinical Practice
Author(s):

Monica Shaw

Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780198569008.003.09

This chapter reflects on the UK Government's approach to tackling patient safety, and the complexities that arise with respect to developing the evidence base on which it is supposed to depend. It explores the problems that arise in estimating the scale of the patient safety problem, including those associated with the definition and measurement of ‘adverse events’ and ‘near misses’. Approaches that seek to make a causal link between medical interventions and harmful outcomes, and those that advocate whole system analysis are critically discussed. The chapter reviews the problems that arise in requiring staff to report on errors, including those of judgement and defensiveness. It concludes with a review of the continuing challenges of the patient safety agenda, and the balancing act between risk aversion and the development of cutting edge treatments.

Keywords:   patient safety agenda, safety targets, adverse events, near misses, systems approaches, reporting cultures

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