Healthcare Safety: The Impact of Disabling ‘Safety’ Protocols

Abstract

With increasing attention to patient safety, hospitals and other clinical facilities are developing practice guidelines and protocols with the specific intent of reducing harm to patients. However, the introduction of these protocols can have unanticipated negative consequences and if followed rigidly can become ‘disabling’. We use the manual count procedure that was designed to improve patient safety by reducing the likelihood of leaving an object (e.g., needle, sponge or instrument) inside a patient body cavity during a surgical procedure to illustrate this point. Using results from an observational study of nine complex operations we show that the count protocol can have unanticipated negative consequences that need to be considered in evaluating the net positive gain in patient safety. The study highlights the importance of evaluating the overall impact of proposed protocols when assessing their potential benefits to patient safety.