Published: 30/05/2002, Volume II2, No. 5807 Page 15
'To err is human, to cover up is unforgivable - to fail to learn is inexcusable.'
That was the message from chief medical officer Professor Sir Liam Donaldson, on the first day of the NHS Confederation conference.He said the mother of a child who was brain damaged at birth because of clinical error had made the first two points. But the plenary session focused on the third element of the process: how to create a learning culture.
Sir Liam was among several speakers to contrast the approach to patient safety in the health service with that taken in industry.
Professor James Reason, emeritus professor at Manchester University and a consultant in human factors and risk management, said that while the NHS had a lot to learn from other industries, it was distinct in several ways. Not least of these was the diversity of the cases it follows and the way that errors tend to be investigated at an individual level.
Professor Reason put it starkly: 'You bury your dead one by one.
There is no Hatfield, no Potters Bar... there is no report that lands on industry's desk.' This meant wider lessons from adverse incidents were not always learnt.
But Professor Reason was loath to condone a 'no-blame' culture.
He called for a way between the person model - 'they name, they blame, they shame, they retrain' - and a system model 'which can be seen as a bunglers' charter'. Instead, a middle ground was needed.
'This is not a no-blame culture but a culture where the line is drawn.Where people can understand what they can report with impunity.'
Dr James Bagian, a former NASA astronaut who is director of the US Veterans national centre for patient safety, stressed that cultural change was as vital as improved systems in lowering risk.
'Accountability systems have taken us about as far as we can go, ' he said, in what could be taken as a warning to the government's enthusiasm for scrutiny and performance management. 'This is where leadership comes into play'.
He said the US had worked to draw a 'clear line' about which incidents were judged 'blameworthy' and which were not. Unless events were defined as a criminal act, involved substance abuse or were deemed 'purposefully unsafe', no punitive action was taken.He said the introduction of such systems had seen the number of incidents reported increase by 300 per cent and the number of near-misses increase by 900 per cent.
And Dr Bagian said delegates should keep in mind the basic good in most healthcare staff:
'People do not wake up each day and think: 'How can I foul up today in a new and innovative way?'' He urged them to abandon the phrase: 'Who's fault is this?'
'You should have your mouth washed out with soap if you say that, ' he laughed.
But his message was in earnest: 'There is an opportunity here to do the right thing. That is all it is.'
Beatrice Fraenkel, chair of South Liverpool primary care trust, asked how NHS staff could be persuaded to report errors and near misses when the current system saw the legal profession encouraging patients to pursue medical negligence cases.
Dr Bagian said he had convinced the US authorities that quality documents on safety should not be publicly available.
'They are only available on the basis that they cannot be subpoenaed, ' he stressed.We said to them [the US authorities]:
'Are you saying that the only way we can learn is by their blood?'
And they couldn't answer that.'