Patient safety, human factors and systems thinking

Overview & Definition

A three-year-old on the ward receives ten times the intended morphine because a decimal point was misread in a handwritten chart, and he stops breathing. A teenager is sent home with a missed appendix because the team anchored to "gastroenteritis." A baby in the NICU gets the wrong concentration of adrenaline from a look-alike ampoule. None of these is, at its heart, a story about a bad doctor or a careless nurse. Each is a story about a system whose defences did not catch a fallible human act before it reached a child. [3] [6]

Patient safety is the prevention of harm caused by the health system rather than by the disease itself. The Harvard Medical Practice Study, which reviewed 30,000 hospital records, found that nearly 4% of admissions involved an adverse event and that around seven in ten were preventable — harm caused not by the illness but by the care meant to treat it. [1] [2] The Institute of Medicine's To Err Is Human reframed those numbers as a public health emergency and shifted the question from "who is to blame?" to "what made this possible?" [3]

The defining idea of this whole field is systems thinking: human error is inevitable, so safety lives in the layers built around people, not in the demand that people never err. Reason put it plainly — you can choose the person approach (blame individuals, rely on perfect performance) or the system approach (build defences that expect and catch human fallibility). Only the second one works. [3]

This page owns the science and practice of patient safety as it applies to children: the language of events and errors, the Swiss cheese model of harm, why paediatrics is high-risk, the interventions proven to reduce harm, and the fixed sequence that follows an adverse event. Cross-link the dedicated leaves for adverse-event reporting and medication-safety detail, for breaking bad news, and for shared decision-making and consent — this page builds the framework, it does not rebuild theirs. [3] [12]

References13Show ledgerHide ledger

1. [1]Brennan TA Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. The New England journal of medicine, 1991.PMID 1987460
2. [2]Leape LL The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. The New England journal of medicine, 1991.PMID 1824793
3. [3]Reason J Human error: models and management. BMJ (Clinical research ed.), 2000.PMID 10720363
4. [4]Wu AW Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ (Clinical research ed.), 2000.PMID 10720336
5. [5]Leonard M The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality & safety in health care, 2004.PMID 15465961
6. [6]Kaushal R Medication errors and adverse drug events in pediatric inpatients. JAMA, 2001.PMID 11311101
7. [7]Fortescue EB Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics, 2003.PMID 12671103
8. [8]Stucky ER Prevention of medication errors in the pediatric inpatient setting. Pediatrics, 2003.PMID 12897304
9. [9]Potts AL Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics, 2004.PMID 14702449
10. [10]Haynes AB A surgical safety checklist to reduce morbidity and mortality in a global population. The New England journal of medicine, 2009.PMID 19144931
11. [11]Pronovost P An intervention to decrease catheter-related bloodstream infections in the ICU. The New England journal of medicine, 2006.PMID 17192537
12. [12]Vincent C Understanding and responding to adverse events. The New England journal of medicine, 2003.PMID 12637617
13. [13]Starmer AJ Changes in medical errors after implementation of a handoff program. The New England journal of medicine, 2014.PMID 25372088