RT Journal Article
SR Electronic
T1 The systems approach at the sharp end
JF Future Healthcare Journal
JO Future Healthc J
FD Royal College of Physicians
SP 176
OP 180
DO 10.7861/futurehosp.5-3-176
VO 5
IS 3
A1 Stephen Richard Harrold Cross
YR 2018
UL http://www.rcpjournals.org/content/5/3/176.abstract
AB A systems-based approach to patient safety has been widely accepted and advocated. Despite this, and a renewed ­emphasis on organisational learning in improving the safety of patients, many patients still suffer unintended harm during their care. This paper reviews the central theoretical themes of a systems-based approach and raises four key questions ­relating for clinicians working at the ‘sharp end’: how can ­clinical teams best apply a systems approach to patient safety, how can patient safety move from a focus on past harm to a proactive approach, how can we avoid a corrosive culture of blame, and what should our response at the sharp end be to seemingly unsolvable problems?