Patient Safety is hard

Its time we stopped beating ourselves up.  Patient Safety or improving the safety of patient care is hard. In today’s world we have spell checkers and prompts to help us with difficult problems.  We have search engines which help us find the most obscure and wonderful facts and figures.  There are even designs that help us get things right; large handles to pull a door (rather than flat plates to push), cordless kettles, brakes and accelerator pedals in the same place on every car.  But for many problems in life and in particular in areas like patient safety there is no easy solution.  So what are some of the things to consider?

expertise – we really should be respecting patient safety as a science that needs scientists – a person who is studying or has expert knowledge of one or more fields.  But with very little on offer to help people develop this expertise (and I dont mean the odd day at a conference) – people struggle on their own to figure out this hugely complex subject.  This also means not diluting its importance by focusing on quality instead (even though we know that quality is supposed to combine safety, patient experience and effectivness – in reality the nuances, the niche or unique aspects of safety are lost)

  • Imagine conducting a full root cause analysis of an incident which had directly led to one or more deaths with no training or experience;
  • Imagine talking to a parent about the serious life threatening error that their child has been affected by with no training or experience;
  • Imagine trying to get a whole organisation to change a particular procedure or piece of equipment they all are wedded to doing or using with no training or experience.

clarity about what works – it is particularly hard to make good decisions when there are competing choices or priorities and it is not clear which interventions work better than others – for example there is a lot of confusing research and data in patient safety; for every researcher that suggests a particular intervention reduces harm you will find another researcher who says it makes no difference – we need to find a way which helps us know which ones to bother with and which ones to park and which ones to stop and ignore altogether.

design– unlike the examples above, we dont seem to use the same principles to design healthcare equipment or packages.  Too many machines have buttons in the wrong place that if pressed accidentally could cause the machine to be turned off rather than a different expected function.  We have to incorporate human factors into design; Don Norman’s wonderful book The Design of Everyday Things written in 1990 is a must read for those working in patient safety.

understand the context – healthcare practitioners will want you to understand how and where they work rather than assume you know. That means getting out there, experiencing what they do; stepping in their shoes as much as you can – not just ethnography, actually experiencing it; this goes for the patients experience too.  Sitting in a wheelchair for the day, getting from theatres to the ward quickly when the crash bleep goes off, trying to wash your hands between each patient contact and so on.

My list of four items above just touch the surface of the patient safety field.  So stop beating yourself up.  Patient safety is hard.  But take heart that you are not alone.  One thing the patient safety field is not short of is a mass of individuals who are committed to figuring it out and reducing the difficulty so that we can truly make that difference we are all aiming for.


I am currently reading ‘Nudge’ by Richard Thaler and Cass Sunstein [Nudge: improving decisions about health, wealth and happiness].  I am hoping to pick up some tips which will help the campaign succeed. Apparently one of the most effective ways to ‘nudge’ people (help them make decisions good or bad) is via social influence.  One of the social influences they cite is peer pressure.

We learnt a while back when delivering ‘patient safety first’ that peer to peer influence was a key success factor in convincing clinicians to adopt a new practice.  It relates to caring about what people think and especially the people around you or those that are like you – often because we want to be liked and we want to conform.  As it says ‘humans are easily nudged by other humans’.

So how does this relate to change?

  • Our experience is that peer to peer influence works for a large section of the population but not all.  There are still those that resist, that do not want to conform.  This has been clearly evident in the use of the surgical checklist or in washing hands.
  • There is also a tendancy for groups to stick to established patterns or behaviours even when changes are desperately needed or even when the original pattern or behaviour is now redundant.
  • People are more likely to conform when they know that other people will see what they are doing or see what they have to say.  This speaks to the compliance culture in the NHS and particularly in the way that people behave differently when being assessed or inspected.  As we all know – the classic description of a culture is ‘one that exists when no one is looking’.
  • People also follow an existing practice because they think that most other people like it; all assuming everyone else must be happy because they have not said any different.

Thaler and Sunstein suggest that a small shock, or nudge, can dislodge these behaviours. For example a city trying to encourage people to exercise more, may simply produce the numbers of people already exercising, plus name a few influential people who are exercising.  These two things (lots of other people exercising and influential people exercising) provides a strong signal that nudges others to exercise.  Encouragement costs nothing.

Apparently if we want to shift behaviour we might be able to do this simply by informing people about what other people are doing!

Happily we have been doing this in the campaign already. Our approach is to inform people about safety improvement activities other people (similar to them) are doing; we have started to create beacon clinical commissioning groups to influence other CCGs to join; and we have been sharing the stories of those considered influential (opinion leaders and respected patient safety experts).  We know that the NHS is one of busy people trying to cope in a complex world – we need to make it easier for them to make safer choices.  Our aim is to influence improvements in safety but also to influence those who are working in safety to think differently about safety and ultimately create a sustained approach to safer care across the NHS.

Sign up to Safety Strategy Year 2

“We have tended to focus on problems in isolation, one harm at a time, and our efforts have been simplistic and myopic.

If we are to save more lives and significantly reduce patient harm, we need to adopt a holistic, systematic approach that extends across cultural, technological and procedural boundaries – one that is based on the evidence of what works”

[Darzi, A, (2015) Health Service Journal, The NHS safety record needs to be as good as the airline and motor industries, [11 February, 2015]

We couldn’t have put it better ourselves.

It’s easy to glance at Sign up to Safety and cry ‘just another campaign’ or ‘why do we need this?’ We know that you are already working on reducing harm, and collectively we have been for over fifteen years. Yet we also know that we have not made the kind of impact we had hoped; patients still fall, we continue to administer the wrong drugs and operate on the wrong leg, and a patient deteriorating can still be missed.

We believe that in part it is because we have focused for too long on single areas of harm in isolation. There is also a huge missed opportunity in that there has been a persistent failure to learn from mistakes and incidents and we know that while many of the interventions that can make care safer already exist, there is a known gap between this evidence and every day practice.

Let’s all think differently about safety.

The next phase of the campaign

To help those who have joined adopt a more systematic approach, over the course of the next year we will be exploring how we can help them focus on the cross cutting system and human factors. This means that they may end up stopping things that are simply not working. We will focus on creating a continuous learning culture which addresses our current failure to learn from incidents and investigations.

We believe that we have yet to understand fully why improvement work is not sustained in the long term and our aim is to get beneath the surface of why there is an implementation gap.

Our programme to bring the pledges to life

Whether you’ve just begun your Sign up to Safety journey, or you’re moving on at speed, the pledges unify us all and are relevant to each individual. From October through to June 2016 we will help you revisit and bring to life the five campaign pledges; put safety first, continually learn, be honest, collaborate and be supportive. All those who sign up are committing to not just believe in, but to embed and be an example of the values and beliefs that make us all proud to work in the NHS. The five safety pledges are more than words on paper. They mean something. By making a commitment to bringing them to life, and by helping others to understand their role in this, we’ll be working together to create the right conditions for safer care.

We’ll be helping you, our participants, keep your pledges front of mind, providing a platform to celebrate progress, discussing what those look like in practice, supporting you to articulate what they mean to all your staff, and sharing your experiences amongst our community. We need your participation and feedback as we move forward. By moving forward together, there is a better chance you will stop feeling like you’re banging the same drum without being heard. You will stop feeling like you are working in isolation. Together we can learn more about how to make care as safe as possible, for each and every patient.

October; Put safety first – Committing to reduce avoidable harm in the NHS by half through taking a systematic approach to safety and making public your locally developed goals, plans and progress. Instil a preoccupation with failure so that systems are designed to prevent error and avoidable harm

December; Continually learn – Reviewing your incident reporting and investigation processes to make sure that you are truly learning from them and using these lessons to make your organisation more resilient to risks. Listen, learn and act on the feedback from patients and staff and by constantly measuring and monitoring how safe your services are

February; Be honest – Being open and transparent with people about your progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong

April; Collaborate – Stepping up and actively collaborating with other organisations and teams; share your work, your ideas and your learning to create a truly national approach to safety. Work together with others, join forces and create partnerships that ensure a sustained approach to sharing and learning across the system

June; Be supportive – Be kind to your staff, help them bring joy and pride to their work. Be thoughtful when things go wrong; help staff cope and create a positive just culture that asks why things go wrong in order to put them right. Give staff the time, resources and support to work safely and to work on improvements. Thank your staff, reward and recognise their efforts and celebrate your progress towards safer care.

Although we’ll be focusing on each pledge one by one, this is your campaign so you may feel our timeline is not the right time for you to use and share the information we provide. That’s ok, and so all resources will be digital so that you can use them at the most effective time for your own local campaign.

Your next steps:

  • Revisit your Safety improvement Plan: Your Safety Improvement Plans are important and represent a lot of work; however we believe that by complementing topic focused work-streams with a focus on some of the most important issues that cut across every intervention, regardless of setting, we will be helping you achieve your goals. So rather than focus on single areas of harm we believe that all of our efforts should shift to addressing the myriad of contributory factors that impact on safety every day; communication failures, the availability and the design of the right equipment, inexperience, stress, attitudes and relationships, and the way we observe patients and use information. All of these impact on safety and apply across the NHS from secondary to primary, acute to community, hospital to GP practice, board to ward.
  • Take part in our programme to bring the pledges to life and share your work: What has your organisation or your area of work or your team done to put safety first? Do you have a story to tell? What actions are you undertaking to bring this pledge to life that you can share for others to use? Even if you don’t think you have done much or you have only just started we are interested in how you are thinking about this pledge.       If you do have something to share or you know some people in your organisation that you would like to recognise their efforts, please get in touch with us via
  • Look out for our e-newsletter SignUPdate: Subscribe and pass it on, look out for notices on twitter @signuptosafety – these are where we will share our learning from the explorations we have mentioned here such as our work on getting beneath the surface of why there is an implementation gap; we will share our videos, your videos, webinars which focus on the pledges as well as the cross cutting themes and we will share a variety of blogs, podcasts, and polls so you and your staff can get directly involved in our shared cause.

Innovation for the future NHS

The diffusion of innovations or new technologies takes a long time.

Currently we have fifteen Acadmic Health Science Networks who have been funded to set up patient safety collaboratives to tackle some intractable patient safety problems using innovation and improvement methods.

However, it may be worth their while to try to imagine what society, social behaviour and attitudes are going to be in the future and how these will impact on the NHS and then design the solutions for the future.

Even once a new idea has been found, spread of any new change can take decades.

What will the NHS look like in decades?

Tricky eh!

What we do know is that we have an unprecedented access to data (but not enough of the right information) we can hear about other people’s work (but not quite understand how they achieved what they did), we have ways to connect people and ideas we couldn’t have even dreamed of a few years ago and social media is changing the way we communicate and who we communicate with – breaking down hierarchies and stereotypical behaviours.

How does this impact on the NHS?

We also know is that we have yet to fully implement the multiple safer practices that already exist.

Perhaps instead of trying to innovate for a future that is unclear we should put all our efforts into working out how to find out what is really working, stopping what isn’t and spread and sustain what we do know works now?

Confidence in the data

Malcolm Gladwell of the ‘tipping point’ fame recently said that more data increases our confidence not our accuracy. If we look at what we know about harm and incident reporting are we growing more confident? I regularly look at the NRLS data and ask myself what it is actually telling me.

I can see that the same types of incidents are reported year on year, and I can see that the numbers of reports increase year on year but am I confident that this is telling me where the most harms are on the NHS or that the increase is good or bad?

The data in the NRLS can tell us facts but they can’t tell us why the incidents happen, they can’t tell us the nature of the harm and the behaviour or factors that led to the incident.

Context is vital but we don’t collect context.

We need new methods to find the truth in data.