Changing the way we look at patient safetyBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2292 (Published 05 May 2010) Cite this as: BMJ 2010;340:c2292
The world of patient safety through the eyes of junior doctor Iain Yardley
It was chaos! Fifty patients to care for, spread over eight wards, four floors, and two wings. Dozens of tests to order. Results to chase. Charts to write. Charts to rewrite. Referrals to make. Discharge summaries to complete. With me and two pieces of paper, one a patient list and the other a job list, to hold it all together.
Despite the chaos, I loved my house jobs. I had made it as a doctor. I had the knowledge and skills to make decisions when faced with uncertainty and was expected to do so. The inherent disorder of the hospital’s system was just another factor that I had to take into consideration when caring for my patients. Of course I grumbled about things in the mess, but it never really occurred to me that things should be any different. It never dawned on me that the confusion could actually be dangerous.
My colleagues, both junior and senior, shared that attitude. The expectation was to work hard and not complain. To try to change the way things worked never seemed to be regarded as an option. Indeed, although I am quite sure none of us would have admitted it, or even were overtly aware of it, somehow we quite liked the confusion. It enhanced our successes, ensuring they were personal and despite, not because of, the system. The ability to cope with whatever came our way was an important part of our professional identity.
Managing the chaos
However, some had noticed not all was well. While I was a house officer, an initiative was introduced to try to bring some structure to the disorder of a busy hospital. The modified early warning system (MEWS) gave a numerical “score” to a patient’s condition and set out a course of actions to be taken should the score exceed a given threshold.1 These actions included an escalating involvement of more senior doctors, should the score not be reduced within a given time. It was simple in its aim and structure. It sought to ensure timely review of deteriorating patients. If junior doctors carrying out simple measures could not rapidly improve their condition, patients received prompt senior review. We hated it.
A little later on in my career another initiative was announced, the “bare below the elbows” policy.2 This required all clinical staff to ensure that their sleeves were rolled up and no wristwatches were worn. The idea was simple: to control the spread of infection by removing potential for it to be carried on soiled sleeves and by making thorough hand washing easier. It cost nothing at all and looked to address one of the most pressing concerns of the time, hospital acquired infection. We hated it.
Then I had an experience that changed my perspective on both initiatives. A patient of mine died, unnecessarily. She died of a hospital acquired, antibiotic resistant bacterial infection. Her deterioration due to the sepsis was clearly documented by the nursing staff, but the severity of the situation went unrecognised by junior medical staff during a busy on-call. Antibiotic administration was delayed, fatally so.
If the clinical staff attending her had worn short sleeves would she never have contracted the resistant infection? Would she have received more senior medical attention earlier had a MEWS been in place? Could her decline have been halted, given timely treatment before she entered the septic spiral that led to her death? Perhaps not, but neither measure would have done any harm. When faced with the devastation her death caused, the dismissal of attempts to mitigate the risks of health care seemed arrogant and misplaced.
I am part of a generation of junior doctors who have trained and worked in an era when the concept of patient safety has gained a high profile. To Err is Human3 and An Organisation With a Memory4 were published the year I graduated from medical school. These documents, from the US’s Institute of Medicine and the UK’s Department of Health, respectively, were landmarks in the process of ensuring that the safety of patients was an important part of healthcare provision. They set out the scale of the problem of inadvertent harm to patients who are receiving health care. The problem was expressed explicitly with the oft quoted and staggering statistic of 44 000 plus deaths each year in US hospitals due to adverse events and nearly one million adverse events each year in UK hospitals. The sources of harm are many and varied, including hospital acquired infections, wrong site surgery, and drug errors. Policy makers and the media also became aware of the problem and patient safety came to the top of policy agendas, including at the World Health Organization5 and the General Medical Council.6 It has been made clear to us all that patient safety is a major problem, a problem that needs to be addressed unless we choose to accept that inadvertent harm is a tolerable byproduct of health care.
Engaging with patient safety
Despite the evidence put before us, as a profession we have still not fully engaged with the issue of patient safety. The reasons for this lack of engagement seem to include a lack of synergy between clinicians and those promoting patient safety. Organisations looking to improve safety make much of “systems error” and “human factors” when describing the origins of error in health care. They try hard to depersonalise incidents, emphasising the multifactorial nature of any incident and the need to focus efforts to improve safety on systems and not individuals.
Despite this, to a group of professionals who conform to an identity that places high value on individual performance, it often seems that doctors are being blamed for the occurrence of adverse events and the intention is to protect patients from us. This is also the impression given in the media when errors occur: “Bungling Doctor Kills Patient” is a more likely headline than “Serial Systematic Errors Responsible for Death.”7 In this climate, acknowledging the need to improve patient safety is to accept that we have failed. We have failed to cope with the demands of modern health care and have failed our patients.
Accepting our shortcomings
The truth, of course, is that we have failed to cope with the demands of increasingly complex health care. This is not to criticise, it is simply a fact that health care has become too complicated, hospitals too busy, and systems too multilayered for it to be possible for doctors to avoid making errors.8 To prevent these errors causing harm to patients, it is necessary to put in place protective measures that will detect or prevent these errors reaching the patient in the same way that a tightrope walker has a safety net to catch him before he hits the ground.
MEWS and the “bare below the elbows” policy can be seen as offering a safety net as we walk the tightrope of clinical practice. The fundamental difference between a tightrope walker and us is that if we fall off our rope, it is not our own lives at risk. That is not to suggest that we casually and deliberately put our patients’ lives at risk. Certainly, the experiences of doctors affected by medical error would suggest otherwise. Doctors suffer terribly when their patients experience unnecessary harm, to the point of being described as the “second victims” of medical error.9 Rather, it is to point out that the reliance on our own ability, which forms such an integral part of our professional identity, is inherently dangerous. It is dangerous because we are all fallible. We will make mistakes. Sometimes these mistakes will belong to an individual. Others will be system-wide and outside our control. Whatever the root cause of the mistakes, they will happen, no matter how good we are at our job.
The acceptance and awareness of fallibility is, taken at face value, at odds with the role of a doctor within a clinical team. We are the ones who make the decisions, who deal with ambiguity, who take the lead. It is difficult to perform this role while maintaining a constant awareness that we may be getting things wrong. Given this inconsistency, it is easy to see how an offer of a safety net could be mistaken for an implication that we are not good enough at our jobs. It is assumed to diminish us as professionals, as anyone who has tried to implement the WHO’s Safe Surgery checklist in an operating theatre will testify. The checklist is at best ignored, at worst ridiculed. The reasons given are: “There is no evidence,” “It takes too long”, “I’ve never had a problem in 30 years,” “I don’t need it,” and so on. The underlying reason for its rejection, however, may be more elemental than that. It may be that the checklist represents an implicit challenge to our professional norms. That we need a mechanistic approach to operating in order to remember basic steps insinuates that we are incompetent. Despite the evidence that surrounds us pointing out ongoing problems,10 we still manage to convince ourselves that it is others who are making the mistakes.
When the conflict between the medical professional identity and the acceptance of fallibility is recognised, it is clear that improvements in patient safety will not come solely from alerts or initiatives. There is a need for a fundamental change in doctors’ attitude and approach to their role. We must accept the need to shift our professional norms. It is no longer acceptable to be completely self reliant. We have to acknowledge the necessity of regulated systems to protect patients, even when this feels as if we are being constrained. Efforts to improve safety cannot continue to be resisted and regarded as unwelcome, bureaucratic interventions by people disconnected from clinical practice, rather than as efforts to help us care for our patients. We need to change our culture.
Making the change
So how will this change come about? Culture change is notoriously difficult, requiring interventions at many levels over a prolonged period.11 Some progress has already been made. As mentioned earlier, patient safety is now a mainstream concept; no doctor could be unaware of it as an issue. There are national and international bodies concerned solely with patient safety. We have senior clinicians championing patient safety and emphasising its importance. Unfortunately, despite these efforts, patient safety is still not the priority of each doctor doing his or her ward round. It seems that a top-down approach alone is not working.
Airline pilots are frequently cited as an example of successful culture change. They managed to change the culture of their profession from one where a daredevil risk taking attitude was well regarded to one where a methodical, cautious, and risk averse approach was highly prized. Their example is so revered that efforts have been made to import their solutions to health care. The idea was that if only doctors could behave a little more like pilots then things could be so different. There is certainly much to respect in airline pilots’ approach to safety and much we can learn from them. However, a large part of their success was due to their ownership of the problem and its solutions. Importing their answers to our questions is unlikely to lead to lasting shifts in attitude. Unless doctors can take possession of their own problem and develop their own solutions, enduring culture change seems doubtful.12
A presentational change to how patient safety measures are promoted may make it easier for doctors to engage with them. The emphasis could be shifted from protecting patients from doctors’ mistakes to supporting doctors who are working very hard in very difficult situations. Rather than implying an inability to cope with the demands of a situation, it would suggest that the role of the professional is so complex that they need support to do it. Taking away the risk of system failures allows individual doctors to concentrate on diagnosing and treating patients, the things that really need their training and experience.
The role of junior doctors
So can junior doctors form part of this change? Could we be the generation that manages to change the culture of the profession from the bottom up? Our goal must be that one day, soon, an efficient, methodical, safety orientated house officer working in a like minded team of professionals will not just be highly regarded but will be the new norm. It will be too late if we wait until we are senior ourselves before we begin to take this on. By then another cohort will have come up behind us and will be in the same position we find ourselves. If we are to be the generation that is to make the change, we need to start to model safety orientated behaviour now and set the example to both those above and those below us.
It should be acknowledged that there is much to be admired in our predecessors’ approach. The confidence to take difficult decisions and lead the care of a patient in the face of uncertainty must be preserved. On the other hand, some behaviour is unhelpful and perpetuates risky practice. The key challenge will be to take the essential elements of what enables a doctor to perform as a doctor and to blend them with an awareness of individual vulnerability and the need for supportive systems to assist us in doing our job.
If a safety first approach can become widespread then it will self perpetuate. Doctors as a group will begin to own the responsibility to improve patient safety. They will develop ideas, frameworks, and concepts to prevent errors. Solutions coming from the profession itself will be far more likely to gain acceptance and make it easier for a safety orientated attitude to become embedded in our professional identity.
It will not be easy and there will inevitably be resistance from senior colleagues and peers who misunderstand or disapprove. It will require us, in an intensely hierarchical environment, to look to our senior colleagues, who inspire us, who train us, who support us, and whom we respect deeply, and say, “We want to be different.”
Competing interests: None declared.