In recent years, patient safety, the avoidance of harm to patients and other kinds of failures in care have all become central concerns within the NHS policy in England. The same is true in many other healthcare systems. In 2013, the National Advisory Group on the Safety of Patients in England, delivered its report ‘A promise to Learn – a commitment to act’. The Advisory Group was led by the Dr Don Berwick, a renowned doctor and campaigner for improved safety and quality from the USA.
The report first sets out a stark reality. “Patient safety problems exist throughout the NHS, as with every other health care system throughout the world” (p4). The report is equally emphatic that the solution does not on the whole lie with blaming individuals, or rooting out incompetent or negligent staff.
Sometimes, of course, individuals do need to be held transparently to account, when they have been willfully or recklessly negligent or involved in mistreatment. However, the report takes a strong stance that safety is best improved and ultimately assured by adopting a broader systems approach to understanding why and how failure or error occur.
The basis of the systems approach, as we have learned from listening to Dr Kevin Fong talk about failures in helicopter ambulances and the Mars space programme, is that human errors are inevitable. However, it is possible to minimize their impact, particularly on the safety of patients, by looking at the way care is organized and seeing how circumstances can make it more or less likely that errors will happen. For example, investigations have shown that elderly patients on hospital wards are more likely to slip and fall when walking to the bathroom in the period immediately after being given medication. So an organisational solution is for staff to be extra vigilant at this time. Similarly, even the best motivated staff get tired or distracted and can make errors in administering medication. The organizational solutions include protecting the nurse doing the medication round from interruptions, and making sure there are multiple ways in which errors can be ‘picked up’, so that the right patient gets the right dose or the right drug. The principle is to put in place mechanisms so that when errors do happen, the impact of those errors on patients is minimized. Understanding better how individuals and systems interact can greatly reduce the likelihood that errors turn into actual failures.
Lawton et al. (2012) have also explored what they describe as ‘latent failures’ that underpin medication errors. Their approach recognises that mistakes are usually made at the front line, and in the case of medicine errors it is likely to be nurses who are at the front line. They also acknowledge that organisations have inherent weaknesses which can be attributed to:
- decisions made at senior level, including those concerning staffing levels and equipment availability
- decisions made outside the organisation, such as education provision and imposed policies.
The ‘Berwick Report’ calls for the NHS to embrace ‘wholeheartedly an ethic of learning’ from failures and near misses. The point is to understand how organizational factors may prompt people to make errors, or prevent them from being noticed early enough. The report argues that the ability to actually achieve this culture and ethic of learning depends on a number of things, above all removing the stigma and blame commonly associated with errors. Staff should be encouraged to take part in investigations openly and without fear or recrimination. This in turn requires leadership that is similarly committed to open-minded investigation and which places the interests of patients above those of meeting financial or efficiency targets. If staff are afraid of the results of not meeting targets, they are not likely to be open about problems they are aware of, which could lead to errors.
This leads to a further precondition – that patients should be listened to and, where possible, involved in investigations into safety issues. The danger is that a pursuit of targets may lead managers and clinicians not to pay attention to awkward realities that patients or their carers try to bring to their attention. Precisely this kind of thing has been documented in detail by Robert Francis QC in his inquiry into how very poor care was some years ago allowed to persist at Stafford General Hospital.
The approach set out by the ‘Berwick Report’ is undoubtedly enlightened and represents the application of some of the most sophisticated knowledge that exists about human error and how to limit its impact in terms of actual failures. There is every reason to hope that what it sets out will help the NHS to improve its safety record.
There is however one crucial challenge involved in all of this – that of consistently achieving adequate staffing levels. The report acknowledges that errors and failures are more likely to occur when the staffing or a ward, clinic, or service fall below what is needed for staff to be able to their job properly. This may happen because of staff turnover or slow recruitment, even when the staffing budget is actually adequate. As a result of the recommendations of the Berwick and Francis reports, hospital trusts in England were compelled to make sure that their staffing levels were consistent with guidelines, from 2014 onwards. This in turn led to a realization that inadequate numbers of nurses were actually being trained, and considerable use of agency nurses, which is a comparatively expensive way to achieve required staffing levels. This in turn led during 2015 to a pattern of overspending across the NHS. Even though this situation is now being remedied, with increased numbers of nurses in training, it illustrates the complexities of achieving safe ways of organizing.
Lawton, R., Carruthers, S., Gardner, P., Wright, J. and McEachan, R.R.C. (2012) ‘Identifying the latent failures underpinning medication administration errors: an exploratory study’, Health Services Research, Health Research and Educational Trust, vol. 47, no. 4, pp. 1437–59.