“Weak” safety culture behind errors, says chief medical officer

Your article (“Weak” safety behind errors, says chief medical
officer, BMJ v326 p300, 8 February 2003) summarises in brief Professor
Liam Donaldson’s approach to the problem of causing harm to patients. It
does not go nearly far enough.

There is little understanding within the healthcare professions of
how errors are caused and what can be done by individuals to improve the
situation. Government and healthcare managers remain mesmerised by the
problems of overspending and waiting lists, and, presumably, are resolved
to address patient safety once the immediate problems are “cured” and
money is available.

There is an adage which has widely been recognised in aviation for
many years – “If you think safety is expensive, try the cost of an
accident”. Some lessons from aviation and other high-risk industries are
being incorporated into healthcare, but not enough. For fifteen years now,
the study of Human Factors and passing an examination in the subject has
been a requirement for all would-be commercial pilots. Rapidly following
on from that, Crew Resource Management (basically, the study of how to get
the most from all your available resources to bring a flight to a safe
conclusion) and also Multi-Crew Co-operation have joined Human Factors.
The Civil Aviation Authority (CAA) requires evidence of six-monthly
recurrent training in these subjects for a pilot to continue flying.

Aviation shares safety information extremely widely. The
circumstances of an incident within one airline are rapidly disseminated
among other airlines, enabling them to examine proactively their
procedures, training and organisation. Where there is fear (however
founded) of victimisation of an individual, confidential reports can be
submitted to CHIRPS, the Confidential Human Factors Incident Reporting
Programme, a charitable trust which liaises closely with the CAA, and
makes recommendations to airlines, airports and regulatory authorities.

Within the NHS, the various confidential reporting schemes need to be
combined. The same errors and human factors contribute to adverse events
across the board of primary, mental health and acute care. It is
unsatisfactory to have one type of incident reported to one organisation
when identical circumstances are reported to another. There needs to be a
much wider range of incident reported to the NPSA, and mechanisms
established so that the circumstances of any adverse incident are
promulgated to all NHS organisations. Every PCT and every hospital needs
to appoint a patient safety officer with direct access to the medical
director and the chief executive.

It is an accepted fact within aviation that human beings will always
make mistakes. Threat of dismissal (or any other threat) will not prevent
it. The entire system of healthcare in the UK needs to be orientated
towards provision of an environment in which the front-line players are
free to be human and their errors are recognised early and prevented from
becoming the type of incident which at present repeatedly damages the
patients. With changeover from addressing active failures of the clinician
to attempting to cure latent failures within the organisation, there is a
danger of ignoring the part that each and every person within that
organisation can play.

The courses provided by Patient Safety Consulting (and other
organisations) can arm every individual with the knowledge and tools to
understand the part that human factors play in every adverse incident,
from how to recognise the warning flags that crop up every time, through
the way we function (or fail to function) in everyday life, to how to deal
with an overbearing senior whose behaviour might endanger safety in such
a way that the system of safety is reinforced and lessons learned.

First and foremost, however, everybody within the NHS needs to be
trained to recognise and challenge all elements of an error chain and all
human factors that contribute to errors endangering patient safety.

Yours etc.,

Captain Ben Hastings, Dr. Thoreya Swage, Patient Safety Consulting

Competing interests:  
None declared