René Amalberti, MD PhD
Professor of medicine, MD, PhD Cognitive Psychology, research specialist in system safety. He is presently Vice CEO of IMASSA (Airforce Aerospace Medical Research Institute) and serves part time as the referent expert patient safety at the Haute Autorité de Santé, France.
Thinking systemic in patient safety
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The medical system is a prototype of an unsafe and dynamic complex system addressing at every minute the challenge of the instable. Work never stops, hospitals never close even when facing excessive demand or/ and (chronic) staff shortage, patients are not standard products, and there is incredible challenging need for a continuous and intensive synergy among a great variety of workers inside and outside the hospital.
Patient safety sounds as a relatively new and promising direction dating back the 90's, with a strong initial input from the US. The first patient safety initiatives have consisted in picking safety models on shelves that were considered successful for the safest industries. In that logic, reporting systems, peer reviews, M&Ms, and a continuous quality improvement approach are still considered forefront to guide and accelerate progresses.
Everywhere the move to safety has been enthusiastic, some figures have improved locally, but the results at the nation level remain deceptive.
Progresses are very slow everywhere in the world.
One of the most complex problems to solve for really gaining efficiency in patient safety at the whole level of the Healthcare system is to control and guide the multiplication of patient safety interventions made at micro and macro level in reaction to the flow of adverse events. Many of these interventions contradict one another, complicate the system, or are weakened by the demands of the field, thus are ineffective and often make the system more fragile and less safe. There is a clear need for a global systemic approach of patient safety.
The lecture proposes the foundation for such a global approach, proposing a way for diagnosing organisational problems, making arbitrations on priorities, assessing the range of safety improvement associated with each category of action, and foreseeing where new safety problems could occur when implementing supposed nice solutions.
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(Met dank aan het Cluster Multi Media van het UMC Utrecht)