Patient safety: why do things go wrong?

Concern over the levels of patient safety within hospitals was raised following a series of studies showing unacceptable rates (3–17% of admissions) of adverse events (injury to patients). Government health agencies acknowledged that the standard of safety for patients was unacceptable and that healthcare providers would be required to tackle this issue. Other industries, particularly in the more hazardous sectors such as energy production, take a very systematic approach to managing safety. They have realized that human factors play a major contributing role to accident causation, but that this encompasses not just the humans operating the system, but also the humans who are managing the organization. Leape and colleagues [1] argued that many hospital systems are designed to rely on the error-free performance of individuals, whereas in industry it is appreciated that human error is inevitable and that accidents occur due to both human failures and latent conditions. Both are influenced by the underlying safety culture of the organisation (e.g. level of management commitment to safety). Drawing on psychological research into safety management in high-risk industries, this paper examines three techniques used to diagnose the state of safety: measuring safety climate; assessing senior managers' commitment to safety; and evaluating nontechnical skills for safety critical positions.