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In the 21st century, we can, and should, be doing better to identify and manage risks and systemic failures in the healthcare system. There is much that we can learn from industries such as aviation, mining and road safety, and from human-factors engineers and cognitive psychologists, about how to shift to a system that, although inevitably high risk, has high reliability (ie, lessons are learnt from problems, and changes made so that the problems do not recur).³ These industries have seriously tackled these issues and made measurable improvements in safety. Healthcare needs to recognise that safety concerns are real, that the system is prone to error and failure, and that we need to work to reduce the risk in areas that are inherently risky.

Ultimately, we need to change the culture in healthcare. As part of this change, all who work in or have responsibility for the healthcare system need to be willing to work with their peers to examine more openly and objectively their performances and patient outcomes. In the broader community, we need to move beyond a "bad apples" approach, with media sensationalism, towards a more mature level of understanding and acceptance of the inevitable risks in healthcare.

There is much to be done to achieve the desired changes. To promote and facilitate these changes, the Australian Council for Safety and Quality in Health Care was formed in January 2000 by the Federal, State and Territory health ministers. Its role is to lead national efforts to promote systemic improvements in the safety and quality of healthcare in Australia, with a particular focus on minimising the likelihood and effects of error.

The Council's first report, Safety first, was presented to health ministers in July 2000. In it, the Council identified the broad areas that it would lead to make "a difference where it counts".⁵ The health ministers endorsed the Council's terms of reference, agreed in principle to provide $50 million for a five-year national program led by the Council, and required it to report annually on progress and planned action. The Safety first report also highlighted the significant personal and financial costs of adverse events^4,6 and noted that existing efforts to improve healthcare safety were valuable but insufficient.

After wide consultation, the Council has produced its first national action plan for 2001.⁷ The major emphasis is on developing and strengthening national standards, with educational support to help healthcare professionals and managers put the standards in place effectively. As no single group can deliver change on its own, a collaborative approach is being taken. Council will work closely with governments, health departments, healthcare funders and management, providers, consumers and educators to ensure that standards developed are put in place and monitored.

A key initiative of the Council is to learn lessons through better use of data. Activities to achieve this will include the establishment of national standards for incident monitoring and investigation in healthcare facilities, as well as the design of improved methods to survey and report improvements in healthcare quality.

The type of activities that the Council would like to see implemented across the country are exemplified in the report from Wolff and colleagues in this issue of the Journal.⁸ They present the results of the long-term risk management activities of the Wimmera Health Care group in Horsham, Victoria. Wolff and his colleagues have developed an integrated clinical risk management program, detected adverse events in a variety of ways, analysed both the events and the risks, and taken action to improve care and monitor progress, using a systems approach. Through this systemic approach, they reduced the rate of adverse events from 1.35% of all patients discharged in the first year of the program to 0.74% in the eighth year. In the emergency department, the rate was reduced from 2.71% of all patients attending in the first quarter of monitoring to 0.48% in the eighth quarter.

These event rates are very low, but comparison is difficult, as the rate of adverse events found in any study depends not only on standards of care and systems design, but also on study methods and the reporting rate. This allows for wide variability in results. For example, other reported rates of adverse events range from 3.7% in the Harvard study,⁹ to 16.6% in the Quality in Australian Health Care study,¹⁰ 30% in a recent study in Victorian hospitals,¹¹ and 45.8% in Florida.¹² The study by Wolff and colleagues was prospective and used consistent methods to detect adverse events, thus allowing meaningful comparisons over time. The important finding was a reduction in rates of adverse events, particularly more serious adverse events. The actions taken to reduce their frequency were simple: changes to local protocols, audits, worksheets and supervision practices, as well as the incorporation of feedback, discussion, checklists and assessment tools. All are low-cost activities. Such information about how to improve safety may well be used to inform the development of national standards by the Council.

Other priorities of the Council during 2001 are:

• to address known high-risk areas which contribute significantly to adverse events. These include reducing hospital-acquired infections, promoting safer use of medications and blood products, preventing patient falls and improving patient assessment;

• to develop national standards for credentialling and performance assessment;

• to develop specialist and vocational registers;

• to develop curricula for educational modules in systems safety, human factors and communication;

• to develop standards for national audits and benchmarking, full disclosure of adverse events and saying "sorry"; and

• to develop standards for organisational certification, accreditation and licensing, addressing such issues as best practice, structured risk management, teamwork and team training, resource use, skill mix and safety standards.

When these priorities have been achieved, the Council will have gone some way towards developing a culture of safety, providing resources for data collection, analysis and feedback, and developing national standards in key areas. It will have a system that is informed by the needs of consumers. There should also be improved morale in healthcare, less unnecessary variation in this care, better performance assessment, more satisfactory outcomes and a reduction in adverse events. The Council will need the willing help of all involved in the system to achieve the benefits available to the community from this ambitious plan.

Bruce H Barraclough
Chairman, Australian Council for Safety and Quality in Health Care
Professor of Cancer Services, University of Sydney, Sydney, NSW

Reprints: Professor B H Barraclough, Department of Surgery,
Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065.

1. Berwick DM. Not again! Preventing errors lies in redesign — not exhortation. BMJ 2001; 322: 247-248.
2. Berwick DM, Leape LL. Reducing errors in medicine. BMJ 1999; 219: 136-137.
3. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000; 320: 759-763.
4. Roughead EE. The nature and extent of drug-related hospitalisations in Australia, 1999. J Qual Clin Pract 1999; 19: 19-22.
5. Australian Council for Safety and Quality in Health Care. Safety first. Report to the Australian Health Ministers Conference. Canberra: Commonwealth Department of Health and Aged Care, July 2000.
6. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Committee on Quality of Health Care in America. Institute of Medicine. Washington, DC: National Academy Press, 1999.
7. Australian Council for Safety and Quality in Health Care. National action plan. Canberra: Commonwealth Department of Health and Aged Care, 2001.
8. Wolff AM, Bourke J, Campbell I, Leembruggen D. A clinical risk management program: detecting and reducing hospital adverse events. Med J Aust 2001; 174: 621-625.
9. Brennan TA, Leape LL, Laird NM. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370-376.
10. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471.
11. O'Hara DA, Carson NJ. Reporting of adverse events in hospitals in Victoria, 1994-1995. Med J Aust 1997; 166: 460-463.
12. Krizek TJ. Surgical error. Ethical issues of adverse events. Arch Surg 2000; 135: 1359-1366.

©MJA 2001
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