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13 - Barriers to Improving Medication Safety

Why Is Patient Safety So Hard?

Published online by Cambridge University Press:  09 April 2021

Alan Merry  and
Joyce Wahr
Alan Merry
Affiliation:
University of Auckland
Joyce Wahr
Affiliation:
University of Minnesota
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Summary

We have seen in Chapter 9 that we have many avenues to improve medication safety in anesthesia and the perioperative period, with considerable evidence and expert consensus to support them. However, human nature, just as it leads to errors, also often drives resistance to implementing safety interventions. Complicating our efforts to improve safety are safety paradoxes that, although would seem to improve safety, actually may work against safety. Achieving improved patient safety requires a deep understanding of not just how things go wrong when error-prone human beings work within complex systems but also why changes that would have a high probability of reducing the risk of errors are so often resisted. Needed changes can be resisted by individual physicians and by entire leadership of a large healthcare system. We return to the concept of violations, and emphasize that failure to hold violators accountable will effectively undermine safety efforts. Finally, an effort to understand why we do not change is absolutely imperative, as our continued refusal to change to safer methods continues to imperil our patients.

Keywords

Patient safetysafety paradoxHigh Reliability Organization normalizaiton of deviancesafety climaterisk displacementstandardizationautonomyteamworkcommunicationhandoffssafety culturepower distancehierarchydisrespecthumiliationshamingculture of respectpsychological safetyerror reportingwalk-araoundscost of safetyelectronic healt recordcomputerized order entryprefilled syringessafety programhuman natureviolationsguidelinesprotocolsvariations in healthcareexpert opinion
Type
Chapter
Information
Medication Safety during Anesthesia and the Perioperative Period , pp. 265 - 280
Publisher: Cambridge University Press
Print publication year: 2021

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