PATIENT SAFETY NOW

You may want to hold on as this is likely to be a bit of a rambling post.

A look back

I am in the 1980s. It is one of my first few wards, I am young and naive but had already fallen in love with nursing. I really had no idea I would, but here I am really happy. One of the patients fell on the ward, so the sister called out, ‘where’s the book’. I wasn’t sure what she meant, so someone else helped me find a red leather hard backed book that looked a bit like an accounts ledger and an excel spreadsheet combined (clearly I didn’t know that then as excel didn’t exist but thats what it looked like in the knowledge I have now!). In the book we filled out the name of the patient, a few other facts I dont recall and the fact they had fallen. That was it. That was our ‘incident reporting system’. The book contained falls and medication errors. That was it.

I am in the 1990s. We now have the words ‘clinical risk’ added to our language and every hospital is now expected to develop a ‘risk management system’ to capture incidents – I set up a very early version of one at Great Ormond Street Hospital where I was now working. So we had ‘health and safety’ and ‘clinical risk’.

I am in the 2000s. The words ‘patient safety’ have become common place as a result of both our anaesthesia colleagues and the work of the chief medical officer at the time Sir Liam Donaldson via a report titled ‘An organisation with a memory’. I am even working for an organisation with the name in the title ‘The National Patient Safety Agency’.

I am in the year 2013 or so, when a new set of terminology arrived on to the scene, ‘thinking differently’, ‘safety differently’, ‘safety I and safety II’. Partly prompted by the frustration that we were not as safe as we expected to be, given the efforts we had put into trying to make things safer.

There were a number of different interpretations of these. The very simplistic of which was the safety ‘before’, the safety ‘current’ the ‘safety I’ was all about learning from the failures. The safety ‘after’, the safety ‘differently’, the ‘safety II’ was all about learning from our successes. It was always a bit more complex than that but it is pretty much how people talk about it now.

In posting my last blog about applying safety II, I was reminded by a responder that Hollnagel has moved on from safety II. He has two modes;

• decremental safety – focusing on taking away risks, hazards and failure points, minimising what goes wrong
• incremental safety – focusing on adding capacity, flexibility and conditions that make everyday work go right

As an aside, a few people wanted to go to safety III. There is no safety III – Hollnagel firmly pushes back on that.

Labels

We like clear labels in healthcare. Name a disease, stick to it, explain it, expand our knowledge of it, but keep to the name of the disease. It helps us and it helps our patients. Just because we know so much more about cystic fibrosis than we ever have before we don’t change the name. It is still cystic fibrosis.

We also might find new diseases or a new virus for example. Not many would have heard of covid-19 before 2019/20. But even then the naming is extremely important. We all need a shared language.

Sometimes things need a rebrand. A new name in the hope that someone might move away from the old name, or the fact that the old name is synonymous with something not working. So the hope is the new label will somehow make it happen. Sometimes we need to create a new name to jolt people into thinking differently, changing the mindset or it helps to explain a new way of working.

Is any of this important?

I think it is. Labels are important. Names give people and things an identity, we know what to call them. Names of plants, diseases, houses, animals – all give them an identity. They are the start of the relationship with those things – that you can have some understanding just from the name and go from there.

All of the labels or names I have mentioned today have the same starting point. The word safety has been around (apparently for more than two millennia says google). Starting out in around 3000 BCE, when it meant ‘whole, intact or well kept’. It further evolved from the word salvus, in latin in around 500 BCE, which meant ‘uninjured, healthy and safe‘. This is the closest we have to how we think of it today. 2,500 years later.

I have read Erik Hollnagel’s latest book. From Safety to Safely and loved it. In it he talks about there can only be one safety and that every safety strategy is either taking away risk (decremental) or building capacity to adapt (incremental). He talks about how managing safely helps us apply safety into our everyday.

The word safely, (well done if you still here!).. emerged in the late 13th century by added the -ly to the trend sauf (safe, unscathed). It was used to mean without risk or harm. In the mid 14th century it added ‘without risk of error‘.

• Safety: noun
• Safely: verb

Over the last 100 years or so safety in healthcare has evolved from a moral duty, to clinical skill, to protection of the public and patients, to the prevention of harm and to the science of safety that we have today.

As much as I think it is important, it is wise to note that the vast majority of people who work in healthcare, just want to work safely. They don’t care about the different names/labels, most have yet to even hear the words safety I and safety II. They care about getting the work done safely, effectively and reliably.

However, 2,500 years and the word safety (from salvus) remains. Must mean something.

I have also been fortunate to have had a long career in all aspects of safety; as a nurse, in a trust, at a national organisational level, in the Department of Health and beyond. Gained a few qualifications along the way. So hopefully I can add something to the debate.

Safety

I think that we can talk about the work that underpins that word, we can talk about the different mindset that you have (with our knowledge of today) when we use that word and the different tools and interventions that we might use in the name of that word. But at the end of the day, if it has stuck for 2,500 years – it’s good enough for me. It doesn’t get better than that.

The expanded meaning of the word is evolving, just like all evolution, safety has had a gradual process of change, adapting and developing in its complexity. Of course it needs to do that.

Adding on bits to it. I now realise, not necessarily helpful.

How we apply safety is the most important bit

What we are all striving to do is what the people hundreds and hundreds of years ago already knew, to ensure (to our best ability) that our patients and staff are ‘uninjured, healthy and safe, unscathed and without risk of error’.

We do that by helping people work safely. We do that by learning from the things that fail, the aspects that go wrong or don’t go to plan or events that are unintended, and unexpected. We do that by learning from how we maintain safety, how we do safety everyday, how we adapt, create resilient systems, how we prevent the failures and how we manage the risks.

The science of safety helps us design environments and design medication packaging so that the vials or boxes don’t look alike. We help make it easy to do the right thing and hard to do the wrong thing.

The latest thinking about safety helps us to understand that the vast vast majority of care goes ok, goes normally, goes as expected. Not because we are perfect but that people constantly adjust, anticipate and adapt to tiny surprises or changes in real time. Thats what we need to understand.

The past has helped us think about safety failures and learn from them but also that, by just investigating failures, we are missing how things get done every day and encourages us to understand why things usually go ok.

The psychologists have helped us think about our safety culture and that people who work in healthcare need to talk about what they are experiencing and feeling. That they might need help to do that, so that someone can put their hand up and ask a question, or to share an idea or even point out when they or someone else was just about to make a mistake.

The cultural experts have taught us that safety needs a way of response. That when something doesnt go to plan we need to respond to the patient with urgency and with explanation and we need to respond to the staff with respect and fairness. That we need a culture where people feel supported and cared for when these things happen so that they can learn and be helped to continue doing what they are doing. That we might enable healing to our patients, their families and the staff.

I think it’s time I stopped adding on words and focus on the timeless practice of managing safety in order to help people work safely.