Approaches to Safety: One Size Does Not Fit All

Abstract

In the previous chapter we set out fi ve levels of care with the levels being defi ned according to how closely they met expected standards of care. We argued that the care delivered to patients frequently departs from expected standards and that this has important implications for the management of safety. Most safety improvement strategies aim to improve the reliability of care and move more closely to optimal care. We suggest that these strategies need be complemented by strategies that are more concerned with detecting and responding to risk and which assume that care will often be delivered in diffi cult working conditions. This argument could be seen simply as an admission of defeat. We might appear to be saying that healthcare will never achieve the safety standards of com-mercial aviation and we must accept this and manage the imperfections as best we can. Errors will inevitably occur, patients will sometimes be harmed and the best we can hope for is to respond quickly and minimize the damage. We would accept that working conditions and levels of reliability are often unnecessarily poor and that strategies to manage these risks to patients are much needed. However, there are more fundamental reasons for widening our view of safety strategies beyond trying to improve reliability. The more critical point is that different challenges and different types of work require different safety strategies. One safety size does not fi t all. Approaches to Risk and Hazard: Embrace, Manage or Avoid The metaphor of the climber and the rock face serve as a framework to introduce our discussion of contrasting approaches to safety. Hazards in healthcare are like rock faces for climbers, an inevitable part of daily life. These hazards have to be faced but this can be done in very different ways. One can minimize the risk by refusing to climb unless conditions are perfect (plan A). Alternatively one can accept higher