The Evolution of Patient Safety

Charles Vincent
Smith & Nephew Foundation Professor of Clinical Safety Research, Department of Surgical Oncology & Technology, Imperial College London

Date: 16 May 2006
Time: 1-2.30pm
Venue: CARR Seminar Room, H615

Abstract
The rising rate of litigation in the 1970s and 1980s was an important stimulus to raising awareness of the problem of patient safety and the development of risk management. Initially risk management had an almost exclusively legal and financial focus, but gradually evolved to address clinical issues and act as a gateway to the underlying problem of patient safety ultimately revealed by retrospective record reviews such as the Harvard Study (1). The Harvard study found that patients were unintentionally harmed by treatment in almost 4% of admissions in New York state. Serious harm therefore came to about 1% of patients admitted to hospital. In the United Kingdom a review of 1014 records indicated a 10.8% adverse events rate, again about half preventable, with a cost of £1 billion per annum in lost bed days alone for preventable events (2). There is also an enormous human cost (3). Many patients suffer increased pain, disability and psychological trauma and may experience failures in their treatment as a terrible betrayal of trust. Staff may experience shame, guilt and depression after making a mistake with litigation and complaints imposing an additional burden.

In the United States organizations such as the National Patient Safety Foundation are pioneering a much more sophisticated approach to patient safety, drawing on research and practice from a number of different industries. The report of the Institute of Medicine on 'Building a Safer Healthcare System' (4) starkly set out the scale of harm of patients and an ambitious and radical agenda for change, which attracted Presidential backing in the United States. In Britain the Department of Health commissioned a major report on 'An Organisation with a Memory' (5), a report covering similar ground to the Institute of Medicine report, which in turn has led to the creation of the National Patient Safety Agency. The British Medical Journal devoted an entire issue to the subject of medical error (6) in a determined effort to move the subject to the mainstream of academic and clinical enquiry, and other leading journals are now running series on patient safety.

References
1. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalised patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377-84.
2. Vincent CA, Neale C, Woloshynowych M. Adverse events in British hospitalised patients: a preliminary retrospective review. BMJ 2001: 322:517-519.
3. Vincent CA. Risk, safety, and the dark side of quality. BMJ 1997;314:1775-6.
4. Corrigan J, Kohn L, Donaldson M (eds). To err is human: building a safer healthcare system. Committee on Quality of Healthcare in America, Institute of Medicine. National Academy Press.
5. Department of Health. An Organisation with a Memory. Report of an Expert Group on Learning from Adverse Events in the NHS. London: The Stationery Office, 2000.
6. Leape L, Berwick D. Safe healthcare: are we up to it? BMJ 2000; 320: 725-6.

Biography
Charles Vincent trained as a Clinical Psychologist, qualifying in 1978 and working in the British NHS for several years. In 1985 he was appointed a research post at examining 'Avoidable Mishaps in Medicine', a joint Lectureship in Psychology at UCL, and St Mary's Hospital Medical School in 1987, and to Professor of Psychology in 2000. Since 1985 he has carried out research on the causes of harm to patients, the consequences for patients and staff and methods of prevention. He established the Clinical Risk Unit at University College in 1995 and now directors the Clinical Safety Research Unit based in Department of Surgical Oncology and Technology, Imperial College London. He is the editor of Clinical Risk Management (BMJ Publications, 2nd edition, 2001), author of Patient Safety (2005) and author of many papers on risk, safety and medical error. From 1999 to 2003 he was a Commissioner on the UK Commission for Health Improvement.

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