I began studying safety and quality in surgical care on the first of April 2003. Up to then, my work had involved developing technology and systems to help improve human performance in a range of other industries, including working with pilots on safety skills and with x-ray screeners at airports to improve the detection of guns and bombs in luggage.
Healthcare was different. Not because the people doing the work were any different – humans are similar wherever you go – and not because the nature of the work was that different, but because of the culture. The first thing that struck me was the importance placed on status within a hospital. The emphasis on seniority and personal responsibility has advantages – senior consultants seem to be able to get things done for their patients that junior colleagues cannot – but also made it difficult to challenge their ideas. However, the bigger jaw-dropping moment for me was when I realised how little learning took place from one patient to the next. This allowed the same problems to happen over and over again. Not that these were obviously serious or caused injury themselves – but they were symptoms of a wider problem. We know that serious accidents happen not through one error, but a sequence of small problems that just happen to line up in the wrong place at the wrong time. The more you have, the more risks you run. Thus, it was those same, seemingly inconsequential things that could be seen to accumulate, unrecognised by the team, to place the patient at risk. It was amazing to me that they never got together at the start of an operation to agree what they were going to do, and that there was no discussion at the end about what could have been better. Doing that alone could have avoided so many problems.
Dropped into healthcare like that, with no training, it was difficult early on to identify whether I’d somehow not understood what was going on. Maybe it was me who was wrong. But the more I looked at it, the more apparent it was that this emphasis on seniority and individual responsibility was misplaced and in some cases dangerous, and the more I questioned the value of such deep-seated cultural and organisational issues. We know that errors can’t be prevented by trying harder or being more “aware”, yet this seemed to be the only solutions offered. It was thought that Doctors who made mistakes didn’t care enough weren’t fit to practice; nurses who couldn’t anticipate the needs of the surgeon weren’t up to scratch. Nothing could be more wrong. Without a team to support them, a surgeon will be unable to function effectively, no matter how good they are, and without good equipment, a shared understanding of what the team is trying to achieve, and a supportive organisation, injuries and accidents are inevitable.
Eight years later, things are better. We’re starting to understand how and why errors happen; how we can build safer systems of work; and to be more open about the personal tragedies of those who have been affected. But there’s still a long way to go. There are still a lot of Doctors, Nurses and Managers out there who don’t believe we accidentally injure 1 in 10 patients, or that there’s anything we can do about it, or believe that “it couldn’t happen here”. None of those things are true.
By accepting that mistakes happen and that we should and can learn from them, everyone can win. Convincing everyone that’s the case is going to take time; but it’ll be worth it.
Dr Ken Catchpole, University of Oxford, 4th April 2011.
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