ABSTRACT
A considerable number of patients suffer from medical harm during their time in healthcare: It is commonly reported that approximately 10 per cent of all hospitalized patients experience harm, of which at least 50 per cent are preventable. The aim of this chapter is to highlight and increase the general awareness of the patient-safety area. A number of models and approaches that describe why accidents happen are discussed, from the early Domino model of accident causation, up to the latest Safety 1 and Safety 2 approach, which takes into account the complexity of today’s healthcare work. The Safety 2 approach also highlights the importance on focusing on why things go right and not only to search for reasons why things go wrong.
Further, the importance of the patient-safety culture in the organization and at the workplace is discussed together with some of its attributes. Whenever we have identified gaps between where we are in terms of safety or quality, and where we would like to be, we need to understand and practice the profound knowledge of improvement to be able to fill these gaps successfully. The need for combining professional knowledge with improvement knowledge is discussed, together with the basic ingredients of improvement knowledge: Knowledge about the system and processes we work in, the presence and effects of variation, psychology of change, and the principles or learning-based improvement work.
