The BBC recently published an online article with the headline “How speaking up can save lives.” Hierarchy, in healthcare and other sectors, inhibits staff from pointing out errors to those in charge, leading sometimes to loss of life. So, we need to train junior staff to raise concerns assertively, and ask senior staff to pay attention when challenged. But these steps will not improve patient safety. The following article explains why.
The landmark report from the US Institute of Medicine in 2000, To Err is Human, estimated the annual cost of patient safety incidents (around US$20 to $30 billion), and drew attention to the scale of the problem.
In the UK, the NHS logs around 1.3 million serious incidents a year, and although 90 percent of these cause little or no harm, around 3,000 result in death, and the service has an annual medical negligence damages bill of around £2 billion.
That bill is expected to keep rising.
The patient safety industry created by To Err is Human now generates a stream of alerts, checklists, guidelines, policies, and protocols,. All the evidence shows, however, that patient safety has not improved.
There are two explanations for the lack of progress. The first is the focus on incident investigation, where implementing recommendations is taken for granted. The second concerns a misunderstanding of the causes of most safety incidents.
Investigations of safety incidents rely on Root Cause Analysis methods. Borrowed from engineering, this approach can lead to ‘root cause seduction’, a preference for simple and rapid solutions, overlooking more problematic system failures.
There is a critical distinction between passive learning – identifying the lessons – and active learning – putting those lessons into place. The process often stops at the passive stage. The problem lies in part with organizational learning.
There is a critical distinction between passive learning – identifying the lessons – and active learning – putting those lessons into place.
But this is mainly a change management issue.
James Reason argues that the causes of safety incidents can be understood using a person-centred approach, or a systems approach. The person-centred approach focuses on individual forgetfulness, inattention, motivation, carelessness, negligence, and recklessness. Counter measures thus include procedures, discipline, naming, blaming, shaming, and retraining.
The systems approach attributes most unsafe acts to the context. Humans are fallible, and errors are consequences, not causes. Accidents arise from ‘error traps’; time pressure, fatigue, understaffing, inadequate equipment, untrustworthy alarms, unworkable procedures. Counter measures thus include changing working conditions, practices, and processes.
The evidence shows that most incidents are caused by system failures, and not by individual misconduct.
What our research shows
We studied the accidental death of a hospital patient.
The investigation identified one cause, a drugs interaction, and many ‘becauses’: critical information not shared; weak shift handover procedures; frequent movement of staff between teams; inadequate training and supervision of junior doctors; poor communication with the patient’s family; ineffective processes for requesting blood tests and monitoring results; drug prescribing guidelines were ignored; structure and contents of medical records were poor; overall responsibility for the patient’s treatment was unclear.
This patient’s tragic death, on the hospital’s own account, arose from a failure in the system of care.
However, three quarters of the inquiry’s recommendations concerned ‘component repairs’, such as revising checklists, guidelines, information sheets, policies, and procedures – steps which are known to have little impact. The investigation used a person-centred approach, concluding that this incident was caused by staff who had not followed instructions.
But the chance of a similar incident happening again is increased if the ‘becauses’ are not addressed. Assuming that staff, who were shocked by this patient’s death, would implement the recommendations, there was no managed change process. Five years after this incident, less than half of the inquiry’s recommendations were completed. Prescribing errors continued.
Mindfulness training – as mentioned in the BBC article – can do no harm but, as a person-centred solution, will have limited effect.
Three things have to happen before patient safety improves.
- The systems approach must be taken seriously and we must stop repeating the fundamental attribution error, blaming individuals and overlooking the context
- We must approach this as a change management challenge, not an organisational learning difficulty.
- Change agendas must start to go beyond component repairs and address the system redesign issues.
Unfortunately, changes to systems and processes don’t make interesting stories and catchy headlines. Fortunately, they are mostly cost-neutral to implement.