Inquiry: Lost in time
Patient safety is not a new issue. So why are we yet to learn the lessons given to us by Florence Nightingale and Sir Rupert Vaughan Hudson 150 and 50 years ago respectively? And how important is the role of design in minimising the risk to patients in healthcare environments?
Pat Young, design specialist, National Patient Safety Agency, UK
In July 1960, Sir Rupert Vaughan Hudson wrote in The Lancet: “The truth is that the open ward is an anachronism. It is socially unacceptable and medically unsound. In 1960 the public, the doctor and the nurse should no longer be expected to put up with this scandalous impromptu.”
Hudson was calling for single rooms to combat cross-infection but he was also writing from a humanitarian point of view. Adverse incidents are estimated to cost the NHS £2 billion a year with a further £1 billion attributed to healthcare acquired infection. Designing for patient safety is one important approach to reducing patient risk.
Latent conditions typically arise from decisions made by management, architects and equipment designers. Adverse events result from errors made by those who provide direct care to patients. Results from a recent survey commissioned by the UK’s National Patient Safety Agency, show that 86% of architects have experienced circumstances that prevented the inclusion of design features which could reduce risks to patients. Sixty percent of architects reported a lack of feedback regarding design features which have created risks for patients.
This may be due to post-performance evaluations not being centrally collated as a learning resource. Of those surveyed, 72.7% agreed that international guidance should be collated to form an international standard for designing for patient safety and 96.9% agreed that improved design briefs could contribute to minimising risks to patients. In the last 10 years, investment in healthcare buildings in the UK has totalled £3.2 billion and yet the debate continues around the fundamental question of single versus multi-bed wards and the impact on patient safety.
If Hudson was calling for single rooms 50 years ago and the health estate is still struggling to include single rooms now, we need to act urgently to build a global knowledge bank where the lessons learnt can facilitate more effective change at a quicker pace to minimise the risk of error and reduce the cost of adverse events.
Chris Sherwood, international development director,
Nightingale Associates, UK and South Africa
In 1859, Florence Nightingale famously wrote: “The very first requirement in a hospital is that it should do the sick no harm.” These words still hold true today. In recent years, the issue of patient safety has been dominated in the UK by its poor record on hospital-acquired infections, giving the issue a prominence here, but not necessarily found everywhere. Our office in South Africa reports that while it is a contributing factor in the move towards single rooms, especially in the private sector, other issues are perhaps more important drivers.
However, there are other areas where the design can positively influence the welfare of the patient by minimising potential risks. Falls are another frequent cause of harm for hospital patients. The relationship between a bed and the nearest toilet/bathroom can be arranged so that a patient never leaves the sanctuary of a wall. This is hugely advantageous for patients with visual and/or mobility impairment.
Indeed, patients on any journey within the hospital are at risk from falls, clinical emergencies and mistakes made during transfer. Judicious planning, creating appropriate clinical adjacencies, can minimise these journeys and the associated risk. A design that facilitates good observation and quick and ready access to a pool of clinical staff can also enhance the safety of a patient. For example, a barn theatre installation such as the one at Nightingale Associates’ Broadgreen Hospital means that during an operation, the clinical team can call on both the expertise and help of others if required.
Sheree Proposch, director, Bates Smart, Australia
Australia’s public healthcare facilities are undergoing a transformational change. Up to eight 100,000+sqm greenfield-site hospitals are currently in design or under construction. This wave of rebuilding creates an unprecedented opportunity to improve health outcomes through an inspired, innovative and informed approach to design.
Current design practice gives patient safety an important role; a great deal of effort has been given to practical and generic patient safety design features – strategies to minimise and eradicate cross-infection, to prevent falls and to reduce or eradicate medical errors (location of hand basins, provision of single rooms, location of ensuites in relation to beds, lighting levels, standardisation, automation, protocols).
A skilled architect can add great value by developing an insight into the atypical issues associated with the project and defining the big-picture impact of a well-designed building. In order to reveal atypical patient safety issues, there is the need for healthy dialogue between building users, architects and equipment manufacturers, and an awareness of exemplar facilities, prototypes and current research. This dialogue should focus on workfl ow analysis and the patient journey.
Some recent examples are: if the patient profile has a large or growing bariatric population, consider providing for hoist journeys from bed or trolley areas to bathroom facilities, including theatres and day medical, or from bathroom facilities to a hydrotherapy pool; in a paediatric or oncology environment, while maintaining observation from the triage desk, provide several waiting room spaces in an emergency department to allow cohorting of patients, such as infectious patients, immuno-compromised patients and, noise-sensitive patients.
We know that access to daylight and views of nature significantly contributes to a sense of wellbeing, calming patient anxiety and minimising stress. Such strategies can improve health outcomes, and also contribute to patient safety. A calm, supportive and well-designed environment allows patients to feel that they are in good hands and not at risk. This allows everyone to focus on safe and supportive patient care.
Charles D Cadenhead, senior principal, WHR Architects, US
I googled ‘patient safety’ today – 33.9m items (oh, dear!). I refi ned my search to ‘design for patient safety’ – 7.5m items (humph!). I again refi ned my search, this time to ‘facility design for patient safety’ – 2.7m items (now we’re getting to something more reasonable!). Lastly, I searched through Google Scholar – 87,200 items. Finely, I had an achievable body of material to read. Well, maybe. It is clear that this is a topic receiving a great deal of attention from many directions. To be anything but a complete adherent could be perceived as heresy.
If I had done this exercise 10 years ago, not nearly so many reports, papers or journal articles would have appeared. Twenty years ago and I’m sure the number would have been comparatively minuscule. Does this mean that architects, 20 years ago, were ignorantly designing health facilities that were harming patients and staff? Some were harmed, no doubt, but we, like physicians, continually learn and refi ne what we do as we practice our profession and train young professionals.
It is inconceivable for a conscientious person to ignore the Institute of Medicine (IOM) publication, To Err is Human (1999, 2000). This, and other studies of the time, were a wakeup call to all in healthcare. It helped to create a new openness when errors were made and a sharing of information among professionals, whether architects or caregivers.
I find it interesting, however, that architects seem to believe that virtually all problems can be solved by architectural design. Patient safety is a huge issue and physical, architectural design certainly plays a role providing places where fewer errors are made.
Some refer to this as simply good design (better work places, lighting, sinks in the right places, connection to nature and on). But I am continually surprised at how few of the topics described in effecting substantial improvements in patient safety are truly architectural in nature. Of 646 ICU safety incidents and contributing factors reviewed by the US Agency for Healthcare Research and Quality in June 2008, not one factor was directly architectural. I am pleased that of the 10 ICU Improvements suggested by the Society of Critical Care Medicine, number six is: “Improve the physical environment”.