It was an absolute honour and joy to deliver the James Reason Lecture in 2016 at the Patient Safety Congress on what was the 68th Birthday of the NHS. Prof Reason was my supervisor for my doctorate and a source of inspiration for over the last 25 years. I will never forget the words; ‘Dr Woodward, now that has a nice ring to it’ when he stood up at the end of my viva and smiled at me as I left the room.
Jim’s work helped us look at the world differently. He is a master story teller and has a unique way of helping us understand what can and should be done. All of us in safety have trailed behind him and owe a great debt of gratitude. I started the second phase of my career in clinical risk and patient safety in 1994. Believe me when I say I had absolutely no idea what I was doing. And Jim Reason came to the rescue. My bible – was his ground breaking book, Human Error. There is such richness in the early thinking of human error that remains as important to day as it did when it was first published. That thinking has laid the foundations for where we are today. But it is the small but perfect book life in error, that has inspired me the most.
Jim says during his career he discovered two key principles:
Learn as much as possible about the details of how people work
And most importantly, never be judgemental
As an investigator you work through facts, you talk to vast numbers of people, you gather statements, you trawl through case notes and observation charts and you review protocols and guidelines; so the first thing you can do is learn to listen.
- Listen to what people are saying without judgement
- Listen to those that work there every day to find out what their lives are like
- Listen to help you piece the bits of the jigsaw together so that they start to resemble a picture of sorts
The second thing you can do is resist the pressure to find a simple explanation. Too often investigations try to create a simple linear story rather than the complex reality of multiple and interacting factors and events. The third thing you can do – as Jim so rightly says – don’t be judgemental. Try to move beyond your own natural bias. As human beings we are intrinsically motivated to find someone to blame. We are also likely to immediately judge the actions on that day as careless or incompetent or to judge past events as somehow more foreseeable than they were, or what we now knew would colour our perceptions of how and why things occurred. So purposefully put these things to one side and look through the holes in the system.
The fourth thing you can do is invest in patient safety skills and expertise. Healthcare is never neat or linear; it is possible to do tasks and activities in healthcare in multiple different orders and multiple ways. What you should find is an insight into the very workings of a busy and complex healthcare environment. It takes enormous skill to conduct an investigation well. The skills and tools needed are consistently under used and their potential under realised and, we are in danger of losing our way and relegating these key components of safety to being simple administrative tasks. The investigation process is viewed with fear and dislike by all and it takes a huge amount of effort and compassion not to be judgemental. This is in a context where Jim has warned us that people are potentially blinkered by the pursuit of the wrong kind of excellence – usually productive and financial indicators and the imperative need to achieve these targets. Jim summed it up in his own unique way; Those whose business it is to manage system safety will generally have their eyes firmly fixed on the wrong ball.
If you have a role in clinical risk and patient safety, like me you have learnt to do your job, on the job. When I trained as a nurse and then went on to specialise in PICU I was carefully taken from the role of a novice through to expert with an in-depth training programme, supervision, mentorship, shadowing, coaching, and tons of experiential learning. Most roles in healthcare, clinical, managerial and admin have all of this together with a recognised body that they can be affiliated with, a bespoke training programme and role models to learn from. In clinical risk, patient safety, incident investigation – none of this happens. Every healthcare facility should invest in creating expert patient safety staff. There is a massive opportunity that most organisations are missing. Employ individuals who are skilled in systems thinking, human factors, cognitive interviewing, behavioural change, mediation, gaining trust, facilitation and delivering difficult news.
The fifth thing you can do is create a compassionate culture where we care for the people who care – along with all those who are caught up in incidents. Every healthcare facility should provide an after event duty of care to all. A function that supports patients and their relatives AND staff when things go wrong. Around a decade ago I came across a radio interview with Bob Ebeling. Bob was one of the engineers working on the shuttle Challenger 30 years ago – since the radio interview Bob has since died. This was his story.
On 27 January 1986, Bob, the engineer had joined four of his colleagues in trying to keep the space shuttle Challenger grounded. They argued for hours that the launch the next morning would be the coldest ever. Freezing temperatures, (their data showed), stiffened rubber O-rings that keep burning rocket fuel from leaking out of the joints in the shuttle’s boosters. For more than 30 years, Bob has carried the guilt of the Challenger explosion. He was an engineer and he knew the shuttle couldn’t sustain the freezing temperatures. He warned his supervisors. He told his wife it was going to blow up. The next morning it did, just as he said it would, and seven astronauts died. Since that tragic day, Bob blamed himself. He always wondered whether he could have done more. That day changed him. He became steeped in his own grief, despondent and withdrawn. He quit his job. Bob is 89 spoke this year on National Public Radio (NPR) a radio station in the US on the 30th anniversary of the Challenger explosion. If you listen to the recording you can hear his voice; it is low, quite and heavy with sadness as recalled the day and described his three decades of guilt.
“I think that was one of the mistakes that God made,” he said “He (God) shouldn’t have picked me for the job. But next time I talk to him, I’m gonna ask him…‘Why me? You picked a loser”.
The listeners were so moved by this they sent hundreds of e-mails and letters of support to Bob. Engineering teachers said they would use him as an example of good ethical practice and other professionals wrote that because of his example they are more vigilant in their jobs. Allan McDonald, who was Bob’s boss at the time contacted him and told him that he had done everything he could have done to warn them; “The decision was a collective decision made by all of us. You should not torture yourself with any assumed blame.” And NASA issued a statement commending courageous people like Bob who they said “speak up so that our astronauts can safely carry out their missions.”
Let’s help all of those people who like Bob are living with the guilt and shame and the people (staff and patients) who are profoundly and forever affected by these events. Let’s care for them; be kind to them, support them to come to terms with what went on and let’s never be judgemental. We can do this by creating a restorative just culture, and a psychologically safe environment where clinicians and patients can speak openly.
And finally..
Thank you Jim – I hope I made you proud.
PATIENT SAFETY NOW 