Healthcare Safety, an Inclusive Approach to Patient Safety
By James N. Phillips Jr. MPA, CFCM, Fellow
Patient Safety has traditionally been defined as being directly related to medical error leading to adverse healthcare events. This rather narrow definition fails to recognize the impact of non-medical factors that also contribute to adverse healthcare events. Under the definition of patient safety, contracting issues such as product recalls, warranty issues, and system compatibly would be disregarded as a non medical error and as such did not meet the aforementioned definition. Since non-medical issues did create adverse healthcare events, what would be the appropriate definition?
Healthcare Safety is a more inclusive definition and reflects the prospective understanding of healthcare safety emphasizing the Analysis, Assessment, and Approach, Figure 1, to potential risk events which may lead to adverse healthcare events or harm. Under this definition the problems we face as contracting and logistics professionals not are aligned with the basic safety strategy of the healthcare organization. In the Department of Veterans Affairs, patient safety has this broader understanding and is seen not just as medical error. Yet in most of its analysis and reporting, the focus has been on that which is closer to medical error and less on business processes and practices which might lead to the adverse healthcare events.
Figure 1 Healthcare Safety Triangle
By redefining and even changing the terms, the perspective changes and broadens the basic understanding by all. Consider the physical composition of an Integrated Product Team (IPT). Does it include Patient Safety/Healthcare Safety people? Consider the charter and subsequent tasks of the IPT. Do they include well developed risk-based questions? Through changing the terms you alter the perspective, creating a greater sensitivity by the IPT. Using the Analysis, Assessment, and Approach methodology, the IPT can better understand the potential risk they are about to enter. Analysis refers to a thorough understanding or the facts as presented and researched. Assessment reflects a risk-based decision on the event and the outcome. Finally, the Approach describes how the IPT would handle each risk event should it actually occur.
In the Patient Safety and Quality Improvement Act (PL 109-41) it states, “One of the main conclusions was that the majority of medical errors do not result from individual recklessness or the actions of a particular group; rather, most errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent adverse events.” (Source: Wikipedia search terms Patient Safety and Quality Improvement Act). It refers to systems and not people!
For the most part, Contracting and Logistics professionals are left out of the loop when looking at healthcare safety when addressing adverse healthcare events.
It is vitally important that we elevate the discussion to ensure that we get a seat at the table. Failing to address these non-medical error adverse healthcare events early exposes the healthcare organization to unnecessary risk!
JAMES N. PHILLIPS JR., MPA, CFCM, NCMA Fellow, is an Acquisition Professional working at the Department of Veterans Affairs National Center for Patient Safety. Disclaimer: his comments are that of his own and do not reflect that of the Department of Veterans Affairs or the National Center for Patient Safety.