Bob Wachter, a leading US clinical researcher/leader (of `hospitalist’ fame) over here on a sabbatical last year mentioned in passing his personal roll-call of influential figures from this side of the water on patient safety research. Jim Reason, Charles Vincent, Mary Dixon-Woods… all social scientists. Where were the doctors? In the US, the leading lights combine research and clinical leadership – Atul Gawande, Peter Pronovost, David Bates, Lucian Leape, Don Berwick.
A few exceptions come to mind – Liam Donaldson, responsible for setting the agenda at a national (and international) level. Tony Avery (GP) and his work on prescribing errors, Peter McCulloch (surgeon) and his crowd-pleasing studies on operating theatres using Formula One handover techniques. And other professional groups have their research luminaries – particularly pharmacy, thinking of the work of Nick Barber and Bryony Dean Franklin, from medication safety in care homes to evaluation of electronic prescribing. Nurse leaders have been prominent in safety campaigns and initiatives (for instance around infection control) – perhaps less notable in research and setting the framework for debate.
But the absence of prominent medics as patient safety researchers and thinkers is puzzling. This may be part of a broader issue – few trust chief executives in this country have a clinical background. In the US, Goodall’s work http://www.ncbi.nlm.nih.gov/pubmed/21802184 showed a positive association between high-performing healthcare facilities and leadership by a physician. My quick googling of chief executives of high-performing trusts (QUEST) on quality/safety markers show none with an obvious medical background, one from nursing. There’s a whole other debate around medical leadership and the interesting hybrid medical/manager role from the likes of Peter Spurgeon and Chris Ham.
Does it matter? Flip another way and you could cite patient safety research as an example of social scientists leading the way – from Jim Reason’s analysis of latent threats and system weaknesses to Charles Vincent and others (Sari, Hogan) measuring the rate of harm to robust evaluations of complex safety interventions (Dixon-Woods, Benning). It has been exciting to see other, newer disciplines outside health come to the fore – human factors (Rhona Flin), design and ergonomics (Peter Buckle). Plus the important contribution of researchers with an understanding of organisational culture and sense-making. I particularly like the paper by Graham Currie and Justin Waring, whose observational study http://tinyurl.com/dy4weak of hospital incident reporting systems showed how doctors determined what counted as safety incidents – for instance, dismissing non-sterilisation of instruments as an issue. In this way, we know that top-down safety initiatives which overlook issues of professional and instutitutional cultures and hierarchies (pace Mintzberg) are doomed to failure.
So there is a good foundation for patient safety research in this country, driven by social scientists http://tinyurl.com/d24xx38. But Atul Gawande’s great insights http://gawande.com/complications into medical and surgical practice show so elegantly the dilemmas of doctors trained for a world that no longer exists. Today’s clinicians need teamworking and communication skills (and checklists) to navigate complex healthcare systems – and an understanding of how those systems work. This kind of insight comes from the inside out. So where are the UK’s Atul Gawandes who will shape the patient safety debates of the future?
