People “tend to overestimate their ability to function flawlessly under adverse condition, such as under the pressures of time, fatigue or high anxiety” and “We must re-examine all that we do and redesign our many and complex systems to make them less vulnerable to human error”
Two quotes from an editorial in the BMJ from 18 March 2000. Who thought this could have been written today?
A safety culture and strong leadership with respect to safety and quality are needed to advance performance. However as the late Bob Wears and Kathleen Sutcliffe stated in ‘Still Not Safe’… we have achieved an enthusiastic but superficial embrace of safety sciences, without deeper understanding. Quality improvement methods may have created a false sense of achievement and we have not achieved wider systemic or cultural change. This is backed up by the Imperial College Patient Safety Report for 2023 which stated a positive and just patient safety culture remains an elusive concept.
Safety currently focuses on when we get it wrong. A consequence of this is a creeping lack of attention to things that go right
Professor Erik Hollnagel
We need to be far more positive about the way in which we approach patient safety. The first statement anyone should make is ‘you did the best you could with the information you had at the time‘. A difficult but essential aspect of safety is people, processes and equipment will fail – we cant make people ‘try harder to stop making mistakes’ it doesn’t work like that. Look at what goes right, as well as what goes wrong, learn from what succeeds as well as from what fails. Yes it is important to understand why things fail but when things do go wrong – assume it normally goes right – ask what happened this time, what was different this time to the norm.
‘why did it fail this time, when most of the time it succeeds?’
Paraphrasing Hollnagel…
By asking this question we seek the answer by finding out what we normally do, what normally happens when it doesn’t fail, what are people doing to maybe prevent that failure from happening. Can we learn from the every day and from the actions of people who may be adapting or adjusting what they do to actually keep people safer. People learn to overcome the flaws in their system because they can recognise the actual demands and adjust their performance accordingly. They interpret and apply procedures to match the conditions. People can also detect and correct when something goes wrong or when it is about to go wrong, hence intervene before the situation becomes seriously worsened. The result of that is performance variability. Not in the negative sense where variability is seen as a deviation from some norm or standard, but in the positive sense that variability represents the adjustments that are the basis for safety. We need to bring together the information we gain from failure together with the information from things going ok and only then make changes (if needed) based on this information. Beware of making changes purely based on failure, you might just impact on how it succeeds
“how are healthcare practitioners able to produce safe and reliable performances despite ….the fallible, imperfect systems, unrealistic rules and incompatible procedures?”
Prof Jessica Mesman
The vast majority of staff in the NHS want to do a good job, to reduce suffering and to be proud of the work they do. However, as Lucian Leape has famously said, ‘some of the best people can make the worst mistakes’. They mainly fail because of the underlying conditions in which they work; the design of the system, care pathways and environment together with human factors such as distraction, stress, teamwork, hierarchical structures and workload that lead to error and harm. Know what systems people in your organisation are working in. Healthcare is a complex adaptive system; Interconnected systems where any disruption affects multiple layers (think ecosystem) and it requires continuous monitoring, rapid adaptability, detailed planning, and coordination across various cultures, and disciplines.
Systems work because people are able to adjust what they do to match the conditions of work
Find out what these adjustments are
- Understand what peoples actual working lives are like. Understand the existing culture – do you have a just and learning culture, is it restorative rather than retributive, do you have a psychological safe environment for people to be able to have their voices heard?
- Provide clear and visible leadership about what is expected in terms of values and behaviours, provide structure and clarity and ensure that people can depend upon each other and the resources around them
- Understand how our natural bias influences decisions about almost everything and in particular can impact on patient safety, the incidents and investigations that follow
- Provide feedback about learning – how many years have we been saying this?!
A map offers you the power of perspective over a landscape. But a map can never replicate what is going on in the ground itself
Macfarlane, R. (2008) Mountains of the mind. London: Grant. (p. 184).
How do we help people to raise their hand and ask a question or to say they don’t know what they are doing or in fact that they may have done something wrong? Psychological safety has been found to be the most important of the five key dynamics for a high performing team (Julia Rozovsky, The five keys to a successful Google team). In fact as Julia says it is the underpinning of the other four. Timothy Clark provides us with some useful stages to achieve this:
- Inclusion Safety – ensure your staff feel safe to belong to the team
- Learner Safety – help people learn through asking questions
- Contributor Safety – ensure people feel safe to contribute their own ideas
- Challenger Safety – help people question others’ ideas or suggest significant changes
And finally…
Negative behaviours such as incivility and bullying, a lack of kindness and empathy all impact on the way we think and behave. In an industry like healthcare that is totally reliant on people being able to adjust their performance, make decisions about complex issues and think quickly in order to keep patients safer… blame and negative behaviours have a big impact on safety
Fostering a culture of kindness enhances collaboration among team members. This leads to reduced errors, improved staff safety, well-being and retention and ultimately improved quality and safety for patients, and their families.
Professor Catherine Crock, Paediatrician, Founder and Chair, Hush Foundation
“If people feel supported and cared for, they are calm, relaxed and hardworking”. Janet Leighton, Director of Happiness, Timpsons
PATIENT SAFETY NOW 