“Weak” safety culture behind errors, says chief medical officer
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7384.300/b (Published 08 February 2003) Cite this as: BMJ 2003;326:300All rapid responses
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Sir,
Safety is an issue in health care, but I reject the limited context
of safety reported by Hargreaves[1], as "patient safety". Health Care
Workers[HCWs] working in bad conditions are an integral part of “errors in
waiting”, and the HCWs themselves are “patients in waiting”.
Though air safety is said to be good[2] and I admit flying safely in
the dark, together with surgeons working by feel, are both neat tricks, I
remain terrestrial, and do still expect to use my eyes to see what I’m
doing at work - regardless of the time of day.
And I don’t care at all that the FDA is reported to believe that
mercury exposure from sphygmomanometers is rare[3] – I still want to know
where my recent estimate of 200 tons of mercury imported annually into USA
hospitals to fix mercurial sphygmomanometers, is presently located, and
why nurses have been excluded from the published reports of mercury
exposure[4].
Using the BMJ Online search screen, I regrettably find no reference
in your journal to the word “lux”, being used in the context of worker
safety. A lux meter measures light, and so can assist in quantifying
working conditions - these are connected to the safety of patients.
Phillip J. Colquitt, Queensland.
[1]"Weak" safety culture behind errors, says chief medical officer
Hargreaves S. BMJ 2003;326:300 (8 February)
http://bmj.com/cgi/content/full/326/7384/300/b
[2] Human Factors are important in Patient Safety. Captain Ben
Hastings, et al. bmj.com, 10 Feb 2003.
http://bmj.com/cgi/eletters/326/7384/300/b#29540
[3] Sibbald B. City bans medical devices that contain mercury
CMAJ 2003 168: 78.
Online free at www.cmaj.ca
[4] Colquitt PJ. Labelling All Sphygmomanometers. CMAJ 2003 eletters
13 January 2003.
Online free at http://www.cmaj.ca/cgi/eletters/168/1/78
Competing interests:
None declared
Competing interests: No competing interests
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
Competing interests: No competing interests
Boards and Department only have self to blame for continuing weak safety culture
The message is not getting across to those at the frontline about
developing a safety culture and that should perhaps not be a surprise. To
borrow and rewrite a paragraph from the conclusion on page 23 of the
Healthcare Commission's December 2004 report on the clinical and corporate
governance failings in the Mid Yorkshire Hospitals NHS Trust it is
possible to understand why.
"It is essential that trust boards and the Department of Health
respond effectively when clinicians raise concerns about the performance
of a managerial colleague. Their concerns should be taken seriously,
treated fairly, investigated fully and any necessary remedial action
taken. Learning from Bristol: The report of the public inquiry into
children's heart surgery at the Bristol Royal Infirmary 1984 - 1995 and a
considerable body of research highlight the need for healthcare
professionals - and that term does not exclude healthcare managers who are
also valued professionals in the NHS - to be alert to shortcomings in
their own performance and that of colleagues, and be willing to report
them."
Unfortunately, reporting "them" sometimes falls on deaf ears and does
not make any difference with the sort of consequences outlined by the
Healthcare Commission's Mid Yorkshire investigation.The safety culture
will not change unless those who preach in organisations also practice as
was made clear by Dame Janet Smith in her Fifth Shipman Inquiry report.
(The views expressd are my own and not those of my employing
organisation)
Competing interests:
Interest in patient safety and manager regulation. Consultant at Pinderfields Hospital, Wakefield 1993 - 2000.
Competing interests: No competing interests