Developing safer health systems takes a long time…a really long time. And the terrible thing is that you can spend years building a better system and it doesn’t take much time to tear it all down.
A smart person once said that trust is earned in sips and lost in buckets…safety feels like that too. You can work really hard and what you build is fragile. I believe that it helps to start with a conceptual framework that we can refer back to as we try to build a safer system. Organizations that are incredibly safe are sometimes referred to as high reliability organizations (HRO). These organizations perform in highly risky areas but they fail much less commonly that you would expect given what they do. I am going to try to show how we might build such a system in healthcare.
The conceptual framework is the roadmap that I will work off of. I think many of the items you will see on this framework are necessary though probably not sufficient to get us to the highest level of reliability. The framework is below and I will refer back to it frequently. More to come.
References: Weick, K.E., and K.M. Sutcliffe. 2007. Managing the Unexpected.