Patient safety research: does it have legs?

• patient safety

Research into patient safety is highly topical. The Agency for Health Care Research and Quality spends about £40M per year under this heading and the UK has established a Patient Safety Research Programme which I direct. Patient safety research is somewhat unusual in that it works back from effect to cause; while most research asks about the effects of structures and process on outcomes, patient safety research starts with the outcome—iatrogenic injury—and asks how it might be avoided. A research programme with an emphasis on safety is needed to determine how and why safety is undermined and hence to develop and evaluate practices targeting safety as their main objective. However, many other research programmes concerned with improving quality generally will impact on safety and a dialogue with these programmes is essential. Similarly, managerial organisations with special responsibility for safety have come into being in many countries. Such organisations, which focus specifically on safety (such as the English National Patient Safety Authority (NPSA)), need to mesh with other organisations (such as the Commission for Health Improvement) responsible for quality generally. Patient safety can be seen as a kind of knowledge management, continually learning, educating and motivating. Patient safety programmes (whether research or managerial) have to be highly connected to the organisations they seek to influence and require a deep understanding, not only of scientific matters, but of the policy environment in which they work.

Patient safety agencies and research programmes have a special duty to reduce single acts which have serious consequences. Note that although the disaster can be traced directly to a single act, that act itself will have multiple antecedent “causes”. This, then, is where patient safety interventions get their bite; they intervene in the chain of events where the probability …