“The easy understandable and completely wrong answer to an incident is to blame those who made the mistake. The correct response is to redesign systems, so that errors are acknowledged, detected, intercepted and mitigated.”
This quote could have been written today, but was in fact written in the British Medical Journal published on the 18 March 2000. Twenty two and a bit years ago. In my much loved and much thumbed copy of issue number 7237 there are numerous articles, in a journal that was solely dedicated to patient safety, that are still very relevant today.
In the following series of blogs I will be talking about the lessons we had at our finger tips all those years ago, the gap between then and now and what we could be doing differently. The blogs also support the launch of my third book, Patient Safety Now out in October which picks up on the themes that I will be exploring over the coming weeks and months.
The editorial in issue number 7237 was written by Lucian Leape and Don Berwick. It was written after the Bristol Inquiry which they say focused professional and public attention on patient safety in a manner unprecedented both for its depth and for the extent of professional involvement. Today in the English patient safety system, since Bristol, we have had inquiry after inquiry. Every time with comments such as this. The authors described an error prevention ‘movement’ and how doctors (the journal was written for doctors by doctors), tend to overestimate their ability to function flawlessly under adverse conditions, such as under the pressures of time, fatigue or high anxiety.
When we think of the last two decades of increased complexity, increased workloads, variable staffing levels and funding along with the almost three year impact of a global pandemic, how do we expect anyone who works in healthcare to ‘function flawlessly’ under our current adverse conditions. In fact even those two words should be reconsidered. We will never function flawlessly all of the time. We can only do our very best given the circumstances we face and the conditions we work in with the expertise we and our colleagues have.
The authors talk about creating a culture of safety by focusing our attention not only to the design of tasks and processes but to the conditions under which we work; hours, schedules, workloads, how we interact with one another and how we train every member of the healthcare team to participate in the quest for safer healthcare. Over the six years of Sign up to Safety we recognised that one of the most important things we could do to help make care safer was to support people to ‘interact with one another’. Helping people talk to one another was at the heart of our campaign.
Berwick and Leape go on to say that making fundamental and lasting changes that will have a major impact on patient safety is much more difficult than simply installing new technologies or solutions. As they say, and we all know, there are no quick fixes. They suggest that we re-examine all that we do and redesign our many and complex systems to make them less vulnerable to human error. They also stated that the then culture of blame and guilt too often shackles us and that we need a culture of learning, trust, curiosity and systems thinking.
I recall this as if it was yesterday. I recall feeling hugely motivated by the entire journal and work that followed on from this. Mostly I recall the hope that if we mobilised our resources and expertise, safety would be everyone’s priority, and healthcare would make the most amazing strides over the coming years.
Reading this, perhaps you can forgive me when I ask, what happened to that hope, why are these words still so relevant today and why are we not safer today given the amount of effort we have put in. What happened in our efforts to take forward the call for action that was made in March 2000. As Carl Sagan says, it is important to understand our past to know why we are where we are in the present and therefore where we might want to go in the future. This was my aim in writing Patient Safety Now, to revisit and explore the really important lessons in our past in order to re-ignite that hope for the future.