Editorial

Citation

Haslam, J. and Cowan, J. (2006), "Editorial", Clinical Governance: An International Journal, Vol. 11 No. 4. https://doi.org/10.1108/cgij.2006.24811daa.001

Editorial

Over the last few years we have been privileged to make regular contributions to this journal. We were delighted when we were given the task of guest editing this edition.

Given the apparent paucity of funded research into patient safety projects at grassroots level we were keen to try and demonstrate risk management in action – making a difference. In our call for papers, we said that we wanted examples of “realistic, unassuming ways in which clinical governance initiatives have made a difference. A problem identified; a solution introduced; a systems error reduced or eliminated.”.

The results of our efforts have been mixed. We know that there are many individuals who have undertaken specific and interesting pieces of work to improve safety and manage risk in their organisation. Yet it proved difficult to get these individuals to submit papers for this journal that would enable others to learn from their experience.

There are a number of possible, and relevant, reasons for this. For many healthcare staff, risk management can be defined as crisis management with some learning from mistakes. In the provision of healthcare, staff are not given the time to deal with things in anything more than a reactive way. There is little protected time for teams to learn and grow together. Furthermore, even when there is such an opportunity, there is then little emphasis on sharing this learning. Again, not all healthcare individuals are given the time – or the training in writing papers that are academically rigorous – to enable them to share the results of their hard work, and allow other organisations to benefit.

In our articles for this journal we have often commented on the unforeseen risks created by changes to healthcare practice. Patient safety is simply not an integral part of healthcare planning. Any change should come complete with a patient safety risk assessment – what risks are there to this approach; how will we help staff identify and learn from mistakes; and how will we help them to share that learning?

The articles for this special edition all reflect the international nature of these concerns, coming from Australia, Canada, South Africa, Ireland and the UK. Changing practice is a broad theme. This is the case whether it is handwashing behaviour, communication skills and attitude or using audit as part of managing risks and reducing mortality and morbidity in a high-risk population. We hope that the lessons are useful and interesting, and encourage you to share your experiences.

Jonathan Haslam, Jane Cowan