Total patient safety is just an illusion in the NHS
Patient Safety The Greek Philosopher Aristotle (384BC – 322BC) said “We are what we repeatedly do. Excellence, then, is not an act but a habit”.
The perception we may have that the NHS in the UK is safe, in my opinion, is currently an illusion. One in eight patients admitted to a hospital will suffer some form of unintended harm, from something small to a “Major Never Event”. One in eleven patients will contract an infection and of the 4.6 million patients undergoing surgical operations about 3,000 a year will die of a preventable error. In Healthcare there is a greater chance of you suffering some form of harm compared to traveling by aircraft or working in the Nuclear Industry. Yet systems and behaviours that will stop the transmission of microbes and cause infections are simple to implement, yet we are missing the trick.
As an Engineer of 40 years’ experience I have worked in the Aviation and Nuclear Industries and I have seen them change beyond all recognition during that time. Their safety systems have evolved from their own experiences of when events have gone wrong, and they have learned from those events to ensure they eliminate the possibility of repeats.
The key to all of this is the culture of the people who work within those industries who embrace the five pillars of safety. Just like the WHO has developed Five Moments for Hand Hygiene, a guideline that defines key moments for hand hygiene in healthcare, implementing these five behaviours and turning them into a habit can and do save lives:
In the Aviation and Nuclear Industries, leadership is the responsibility of everyone “Safety is treated as a top priority.” Healthcare is no different. I believe it is necessary to examine the principal factors that lead to error events and learn lessons from what happened.
The Aviation and Nuclear Industries agree on two fundamental principles, listening and learning. Every individual should feel free to raise concerns and any problems without fear of retaliation. Two, when employees report problems, those problems are promptly listened to, addressed and corrected.
In these Industries, Nothing in isolation, all incidents, from failed communication to minor or significant errors, requires investigation to explain how the system could have prevented them. Incidents are investigated and reported and learning is distributed globally to ensure lessons learned are shared by all.
Achieving excellence, means being at your best—matching your practice to your full potential. Excellence means being better tomorrow than yesterday, which implies that the standards of excellence continually change. Pursuing excellence, therefore, promotes the highest levels of standards and safety.
Organisational systems, such as “Systems thinking” is the process of understanding how systems influence one another within a complete entity, or larger system. In organisations, systems consist of people, structures, and processes that work together to make an organisation either "healthy" or "unhealthy".
Reporting, communicating, creating a culture of learning is not about assigning blame. Showing leadership, being the best you can be, not being afraid to challenge mediocrity when peers don’t wash their hands or follow the procedures that are there to deliver safe care can only benefit the NHS and give it the “World Class Safety Status” it deserves.