Rob Bethune is a surgical registrar in the Severn Deanery. He was a founding board member of The Network (www.the-network.org.uk ) an on-line social media site for healthcare professionals wanting to share their learning and connect with other quality improvers around the world. He has been involved in a regional wide programme facilitating junior doctors to run quality improvement projects.
I have to put my hand in the air and say ‘I’m guilty.’ I, like many doctors, never really reported safety incidents in hospital, and the reason why I did not do this is complex. I am a huge believer in improving quality and safety and have spent almost all of my non-surgical time over the last 10 years working on programmes to reduce safety incidents and improve quality. So why did I not report safety incidents in my own clinical practice? I think I just went along with the prevailing culture: ‘it’s too hard’, ‘the forms take ages’, ‘nothing will ever happen as a result so there’s no point doing it.’ I just accepted these as truths and since I had a clear avenue (via quality improvement) to change the systems around me I never challenged those assumptions, until now.
So what has changed me? I read a book. Not a patient safety book, but a book about the airline safety system. If you are interested, it’s called Close Calls, by Carl Macrae (Palgrave Macmillan – you can read a sample chapter by clicking here). He spent three years with airline safety investigators really trying to understand what they do and how they do it. Here are some thoughts on the main messages I got from his book as we look towards developing the same system in healthcare:
1) The judgement of safety investigators is not directed at the specific crews in question, nor is there any individual blame. Investigators’ concerns are related to how the incident happened, and most specifically on how the systems can be improved to reduce the chance of it happening again. This ‘no blame’ culture goes even further in a statement signed by the airlines chief executive stating: ‘that investigations are to focus on learning and improving safety. No staff will be considered culpable, or will be punished, for errors or mistakes made within accepted professional conduct and that are appropriately reported’. Basically, if you’re not negligent then you will not be blamed or held accountable. Are we anywhere near that in healthcare?
2) Airline safety investigators are almost all drawn from either current or previous frontline line workers. To work as an airline safety investigator you need experience of analysis as well as knowing what gets done on the frontline. During their investigations they often refer to their own previous firsthand experience, and think: ‘I’ve done that.’ I think we do have this in healthcare too, since investigations are normally carried out by a clinician as well as a safety investigator.
3) Although they have a formal process of reporting incidents and near misses, there is also an informal system so that anyone can contact the safety investigators with more ‘feelings’ that something is not quite right. The investigators can’t do much with one report but if they start getting a multitude of ‘feelings’ then they will take action. As I say below, the reporting system in the hospital I work in does actually allow this.
4) They communicate clearly, publically, and across the industry. Flight safety investigators only significant influence is to report internally and publically the incidents. They do this in a variety of ways. On a weekly basis they report to senior management a brief summary of incidents. On an operationally useful side, they produce a monthly newsletter for all frontline staff and a more formal quarterly magazine focusing on practical safety issues. After the crash on the Hudson River, the formal report had been published online and was freely available to anyone to view (click here to see it, it makes for interesting reading). To the best of my memory I have only ever seen three reports of patient safety incidents in my 13 years of clinical practice.
5) They accept the inevitability of accidents; there are no ‘never’ events. Failure and error are inevitable features of organisational activity, and though such incidents are largely manageable, they are ultimately ineradicable. The airline industry works constantly to try and prevent them, and this perceived inevitability makes safety investigators continually attentive and worried. This is James Reason’s ‘constant sense of unease’.
6) Their work is totally dependent on incident and near miss reports. The reporting of incidents allows investigators to see what is really going on and keep in touch with the frontline. Without these reports their job would be impossible. They get very nervous when reporting starts to drop off. Is it because the frontline is losing the faith in the safety systems? You need staff to be totally happy in reporting mistakes and errors, both because they will not get in any trouble and also because something will be done to make it better. As Carl says, ‘the engine that drives safety is events.’
It’s this last point that has changed my attitude to reporting. The airline safety system is totally dependent on frontline staff putting in incident and near miss reports. Theirs has been a journey of moving from crash investigation (which they did from the beginning when there were lots of crashes) to a system that analyzes near and not so near misses.
As a result of all this, I’ve now started reporting any ‘unsafe things’ – the near misses as I have seen them. From the more serious (unfilled posts when the locum SHO did not turn up) down to the absence of marker pens on the pre-op admission ward. It may not sound like much, but this is a significant patient safety issue. I had to search around another ward to find this missing marker, but could I have just used a biro if I’d been more pressed for time? This has happened before in a hospital I worked at and actually led to an operation on the wrong lung!
So how about my initial fears. It was really easy to fill the forms out on the computer system, took hardly any time, and even had a box for free text. I got an automated reply thanking me after I’d submitted. I then emailed after a couple of weeks to find out what was happening, asking to see if I could spend some time looking at how the incident forms where handled. I was waiting for the reply and any more information about what has happened. However, it is over two months now and I am still waiting.
Perhaps my fears were well founded, I will let you know.