New policy developments indicate the health service is belatedly moving in the right direction on keeping the public safe from harm, writes Martin Bromiley
I sat for 13 days watching my then wife die, unconscious and brain dead. I had lots of time to think, my overwhelming thought was “I don’t want this to happen to anyone else”.
I took a deliberate approach to how Elaine’s death should be investigated. It was inspired by the AAIB approach, and I was specific, it was about “learning, not blaming”. The end result has been learning on two levels. Technically anaesthetic practice has changed - and lives have been saved. I know that, I get the emails thanking me.
But learning has also happened on a more fundamental and much bigger level, supported by a large dose of work and interventions from many clinicians working with the Clinical Human Factors Group who recognised that there was a system problem.
It seems in healthcare the belief prevails that bad things are caused by bad people; and a disbelief, even a denial, in the normality of error. This means systems are made with the assumption that errors won’t happen or that problems will always be resolved by the final line of defence, the frontline. And when that doesn’t happen we blame the frontline. Or the frontline deny.
A safe place
So safety critical industries aspire to a “just culture”, where reckless, grossly negligent or deliberate acts are punished, but inadvertent human error freely admitted is not sanctioned. If you like, a safe space is developed. This encourages people to talk about what happened, be honest and open. None of this stops victims being rightly compensated for their loss, and of course accountability is taken very seriously in other industries. But learning must come first to create better safety.
Systems are also built to be as error tolerant as possible, designed to make it easy to do the right things, first time. Multiple defences are built into systems and the final line of defence, the operatives, are trained and performance managed to behave in ways that make it easy for others to do the right things around them. Including speaking up. To understand the evidence base for making it easy to get things right first time you need to understand human factors, both at a leadership level and at the frontline.
This week has seen a number of policy directions taking shape. A focus on learning, not blaming
This week has seen a number of policy directions taking shape. A focus on learning, not blaming. A focus on understanding the system so it becomes easier to do the right thing. A focus on human factors. But none of this will be easy; as I write the Healthcare Safety Investigation Branch Expert Advisory Group are thrashing out the details of how a “safe space” might work. And none of this heals the past for those already harmed.
But at last the NHS is taking investigation, system safety and human factors seriously. The result will be a better, safer healthcare for all. This is about the future. The first thing every harmed patient and clinician has said to me, is “I don’t want this to happen to anyone else”.
Martin Bromiley is chair of the Clinical Human Factors Group