Turning negatives into positives: the importance of learning from mistakes

It is nearly four years since Professor Don Berwick’s National Advisory Group published its report, A Promise to Learn – a Commitment to Act. At the time there seemed to be both political and professional will to embed a patient safety culture in the NHS. The National Advisory Group’s overarching goal was expressed in clear terms:

“Patient safety should be the ever-present concern of every person working in or affecting NHS-funded care. The quality of patient care should come before all other considerations in the leadership and conduct of the NHS, and patient safety is the key dimension of quality.”

Although patient safety in itself is not a solution to the spiralling cost of clinical negligence claims in England (where legal reform is needed), it will be no surprise that medical defence organisations have long advocated support of patient safety initiatives. Putting patient safety at the centre of what we do in medicine is the right professional and ethical thing to do.

Although it may appear that little has happened since the Berwick Report, a major new patient safety initiative was launched in April this year, when the Healthcare Safety Investigation Branch became operational. It will aim to investigate up to 30 healthcare patient safety incidents each year – but the objective is not to blame or discipline those involved, but rather to develop meaningful safety recommendations.

The HSIB will be independent, a quality seen as key to its success and, as well as undertaking investigations itself, it will seek to improve standards of patient safety incident investigations generally. The latter point is an important one: learning from what goes wrong in healthcare needs a holistic approach, not a fractured one that focuses disproportionately on one type of incident, such as so-called “never events”.

‘It is too easy to think of patient safety as an abstract concept: something that is academically interesting but not really relevant to those who are busily getting on with treating the millions of patients seen each week in the NHS’

All events that cause harm or distress to patients are important and developing both the skills and the culture to allow for professional investigations delivering relevant and achievable learning points, should be a key objective of NHS organisations. One of the aims of a major conference in London this October will be to help understand how to turn a negative into a positive when things go wrong by learning from risks and errors in decision making.

It is too easy to think of patient safety as an abstract concept: something that is academically interesting but not really relevant to those who are busily getting on with treating the millions of patients seen each week in the NHS. To do so misses a fundamental point: quality and safety are the responsibility of everyone who provides clinical care to patients. And don’t just take that from me, this is what the experts contributing to the Berwick Report said:

“[NHS frontline staff should] commit to learning about patient safety as a core professional responsibility and develop [their] own ability to detect problems” [page 23].

You can register for the PIAA international conference, which is being co-hosted by the Medical Defence Union and Medical Protection Society, here.

Dr Michael Devlin is head of professional standards and liaison at the MDU