History of the CSRU
Background and Context
The profile of patient safety has been increasing in the last few years. Studies in the United States , Australia and Britain suggest that 4-16% of patients admitted to acute hospitals are harmed in some way by medical interventions.
In response to these findings and some high-profiole tragedies, governments have foucssed more attention on improving safety in healtchare. In Britain the Department of Health commissioned a major report `An Organisation with Memory', which gave the figures for known harm at that time: 400 people known to die or be seriously injured from events involving medical devices; nearly 10,000 people known to have experienced adverse reaction to drugs; and hospital-acquired infections costing the NHS nearly £1billion. It described the NHS as having an old fashioned approach to learning lessons when things go wrong, and set out a way forward designed to enable the NHS to successfully ‘modernise its approach to learning from failure’. This has been followed, in May 2001, by `Building a safer NHS for patients' which described the new national incident reporting system and established the `National Patient Safety Agency' to synthesis and disseminate learning from these adverse events.
Although much has been done to bring improvements to patient safety in England, there remains a frustration that improvements have been slow’. Following a review of progress during 2006, the Department of Health issued a document last December entitled ‘Safety First’. The key message is summarised in a quote by the chair of the regulatory body, the Healthcare Commission, Sir Ian Kennedy: ‘Safety cannot be allowed to play second fiddle to other objectives that may emerge.
The CSRU
Professor Vincent has carried out research on errors and adverse events in medicine since 1985, and been closely involved in the development of risk management and patient safety in Britain . The Clinical Risk Unit, based at the Department of Psychology, University College London, carried out research on a wide range of safety related topics. These included the nature of errors in radiographic interpretation, the analysis of major obstetric incidents, the impact of litigation on staff and patients, the communication of risk information to patients, the nature of safe healthcare organisations, the role of incident reporting and the epidemiology of adverse events. Other research focused on developing a conceptual framework for examining risk and safety in medicine, the use of human factors techniques from other high-risk industries and the development of systematic methods of investigating critical incidents in medicine.
These research themes were brought together to create a Clinical Safety Research Unit at Imperial College, to develop safety related research while maintaining the existing programme of work on surgical skills.
The Unit has two broad, related aims. First to continue research on the development of surgical skills, including examination of team performance. We also intend to examine the whole process of surgical patient care, using human factors techniques adapted for healthcare, to examine the risks and potential for errors and harm at all points in patient care. Secondly, we have a wide ranging programme of research which aims to produce generalisable lessons and interventions which are applicable across a range of healthcare environments.