PATIENT SAFETY NOW

How do we become better listeners?

How do people whose jobs depends on avoiding harm and preventing unintended events notice that something isn’t quite right and how can we listen to them?

The sailor

A good sailor rarely waits for the storm. They’re constantly scanning. Noticing…

• the wind changing
• a subtle shift in swell
• clouds building
• the feel of the boat
• the sound of the rigging
• birds behaving differently

None of those things, on their own, mean disaster, but they are really good clues.

The chef

A chef doesn’t need a dashboard to know service is about to unravel, they notice…

• orders starting to stack up
• someone unusually quiet
• ingredients running low
• a station becoming cluttered
• conversations becoming shorter
• people stopping helping each other

Nothing has gone wrong yet, but everyone can feel that something is changing.

Gosh that feels like some of the shifts I recall at work.

So how can we get better at noticing these things? The tiny hesitations, the staff looking uncertain and uncomfortable, energy levels changing, confidence decreasing.

The people who are doing the work know what gets in the way of doing that work. People already know the weak signals and are trying to tell others. Usually repeatedly through an incident reporting system, which sadly is a weak way of telling people because it is usually overwhelmed with data.

• We have been short staffed for weeks
• The equipment keeps failing
• We keep having to adapt of workaround what we are supposed to do
• Things feel different today
• We nearly missed something or forgot something or did something yesterday

Most of these don’t lead to harm because someone has ‘coped’. People know the processes are awkward, the workarounds that have become normal, the clinics that overrun, the software that never quite works, the days when it feels risky.

Lets start by asking the right questions and then listening

Huddles, handovers, meetings. Or simply ending the day by asking:

• What made work harder today?
• What nearly caught you out?
• What have we become comfortable with that we shouldn’t?
• What have we started accepting as normal that shouldn’t be?
• What are you worrying about that no one has asked you?
• What feels different this week?
• If nothing changes, what concerns you most?

Looking at changing conditions

Many other industries conduct thousands of informal observations. Importantly, they aren’t looking for mistakes. This is where VRE – Video Reflexive Ethnography – would work brilliantly. Simply filming of a task or process or meeting (whatever you want to focus on) and share it in a reflexive meeting with the people involved and ask questions. The following are just prompts – you don’t have to ask all of these.

1. Start with observation

• What are we seeing here?
• Can you talk me through what is happening?
• What is this person trying to achieve?
• What happens next?
• Is this what normally happens?

2. Explore work as actually done

• Why did you do it that way?
• What influenced that decision?
• What information were you working with?
• What were you paying attention to?
• What were you worried about?
• What would someone not familiar with this work miss?
• What nearly made this more difficult?
• What slowed things down?
• What almost didn’t happen?
• What made you pause?
• Where did you have to recover?
• What could easily have gone differently?
• Is there anything here that has become “normal” that perhaps shouldn’t be?

3. Identify adaptations

• Where are you having to adapt?
• What workarounds are you using?
• What usually gets in the way?
• Which parts of this process are the most difficult?
• Where do you have to rely on experience rather than procedure?
• What makes this work go well?

Rather than asking, “What went wrong?”, VRE asks:

• What made this successful?
• What would make this easier?
• What opportunities do you see for improvement?

How good are we at really thinking about the near misses?

They are often dismissed. James Reason called them the ‘phew’ factor. Phew I nearly did something but it didn’t happen. They might be little things that just happen, we are all human, but they just might tell us something about what is going on in the system. It may also tell us something about ourselves, that we are tired, or hungry or getting forgetful because we are so stressed.

The three buckets was a fun and I think useful initiative that anyone could do. It was part of the Foresight Training Toolkit developed by the NPSA (National Patient Safety Agency). Used to help frontline staff to think about the conditions that increase the likelihood of error. It encouraged people to consider the effect of factors related to Self, Task and Context (the 3 buckets).

Ref: Three buckets

So:

Self – factors affecting the individual (fatigue, stress, illness, distraction, knowledge, experience)

Task – factors relating to the nature of the work (complexity, unfamiliarity, time pressure, design of the task)

Context – factors in the working environment (staffing, interruptions, equipment, leadership, communication, workload)

James Reason’s underlying message was that the probability of an unsafe act is determined by the amount of “bad stuff” in the three buckets. As the buckets fill, the likelihood of error increases—not because people become careless, but because the conditions make error more likely.

If you asked staff at the start of every shift “Which bucket feels fullest today?”, you’d probably uncover many of the weak signals that never make it into incident reports.

None of these are about developing performance management data systems or trying to catch people out or finding the mistakes. They are all simply about listening. As Margaret Wheatley once said..

“The simple act of truly listening to another, with respect and curiosity, changes everything”