First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality

Abstract

Healthcare systems across the world and especially those in low-resource settings (LRS) are under pressure and one of the first priorities must be to prevent any harm done while trying to deliver care. Health care workers, especially department leaders, need the diagnostic abilities to identify local safety concerns and design actions that benefit their patients. We draw on concepts from the safety sciences that are less well-known than mainstream quality improvement techniques in LRS. We use these to illustrate how to analyse the complex interactions between resources and tools, the organisation of tasks and the norms that may govern behaviours, together with the strengths and vulnerabilities of systems. All interact to influence care and outcomes. To employ these techniques leaders will need to focus on the best attainable standards of care, build trust and shift away from the blame culture that undermines improvement. Health worker education should include development of the technical and relational skills needed to perform these system diagnostic roles. Some safety challenges need leadership from professional associations to provide important resources, peer support and mentorship to sustain safety work.

Keywords: data collection; health services research; neonatology; nursing care.

Figure 1

Illustration of how a skilled practitioner might combine their insider knowledge with a more analytical outsider perspective to examine how the external and internal environment, the organisation of work and the different groups of people who conduct tasks, using the tools and technologies available to them, all result in the actual processes and outcomes of care. In this diagram, the inner arrow represents the main care activities, these are often defined on a medical round, as here when baby Bahati was started on a new course of antibiotics and oxygen (shift 1). The Newborn Unit (NBU) team uses tools and technologies (eg, patient monitoring charts, pulse oximeters, weighing scales) and is involved in team-based activities (all encompassed in the blue cylinder). Wider organisational activities also continue (encompassed by the brown cylinder) such as the three shift changeovers. Some of these activities (eg, handing over or ordering supplies) require engagement with other hospital departments or teams. Other activities are less predictable but may strongly influence practice (eg, unexpected staff absence or dealing with a distressed parent). All of this activity takes place within a wider environment (represented by the black cylinder), which can influence NBU care (eg, inadequate supply of medicines or failure to recruit new staff). We highlight using red text how multiple contributing factors that affect baby Bahati’s care (panel 2) combine to produce important process failures and subsequently harms.

Figure 2

A simple process map representing how drugs are ordered, dispensed and administered in our imaginary Newborn Unit (NBU). Key initial actors (left of figure) include the pharmacist, nurse 1 who collects the drugs and nurse 2 who later gives the first dose of drug. In our example, the process involved a sequence of activities (rectangular boxes connected by unbroken arrows) that took place without any active checking or decision-making steps. We have added potential decision-making or checking steps that would create a new pathway (illustrated by the diamonds and the broken arrows) that six points at which a drug error (panel 1) might have been averted or detected. In our example, as it was not a routine practice to check drug vials for the preparation they contained the drug error was repeated over several days (by nurses 3, 4 and 5).