Health Director

Life Saver

We are entering a new decade. Patient safety is still a young and rather embryonic search for reliable methods for ensuring that patients are protected against avoidable harm from healthcare. It is the sometimes embarrassing backdrop to the other fact that the great majority of our NHS care is of a very high clinical standard and that survey evidence indicates very clearly that patients perceive it very positively.

Nevertheless, unfavourable comparisons between medicine and other high-risk industries have been made before. When a person steps on a plane, their risk of dying in an air crash is one in 10 million. When a person is admitted to hospital, their risk of dying or being seriously harmed by medical error is one in 300. Several international studies of healthcare systems have all reached broadly similar conclusions on the level of risk. There may be greater uncertainty about the precise proportion of such harm in events that are readily avoidable, but there is little dispute that it is significant, and that it is at a level that we should not be prepared to accept. We can take encouragement, however: we have made impressive progress, despite it being less than 10 years since concerted efforts to improve patient safety began.

2000–2009: a decade of recognition and improvement

In 2000, two studies helped inject a sense of direction and urgency into the understanding and reduction of error in healthcare. In the UK, we saw the publication of ‘An organisation with a memory’, a report by an expert group that I chaired. This report described the scale of the error problem, the lack of consistent reporting of incidents and the lack of investigation. The report also noted the opportunities for avoiding incidents that went ignored, emphasising the need to learn from the experience of other sectors in order to strengthen our safety culture, and systems for safety.

Similar themes are to be found in the US Institute of Medicine report, ‘To err is human: building a safer health system’. This included a comprehensive explanation of how the setting of performance standards and expectations for patient safety could aid improvement. This linked the role of professional certifi cation or regulation of healthcare practitioners and of organisational accreditation to driving improvements.

A refl ection over the last 10 years of growing emphasis on the importance of patient safety might reveal that one thing we have learned is that knowing what can make healthcare safer is only one part of the task. Knowing how to improve behaviour, at both the individual and at the corporate level, has to be an essential component of reliable improvement. The task is considerable: improving safety is relentlessly hard work.

The National Patient Safety Agency (for England and Wales) was established in 2002 and has developed a wealth of evidence and of expertise on the problems and solutions of patient safety problems. It has the largest and most sophisticated national reporting and learning system anywhere in the world. Over one million patient safety incidents are now reported each year. Around 92% of these incidents are classified as ‘no harm’ or ‘low harm’ but represent a unique source of understanding of how errors occur and of how they can be avoided before they escalate into more serious events.

NPSA surveys incident reports every week to identify cases of serious harm or of death. This is the front end of a rapid review and response system designed to ensure that lessons can be learned quickly and preventative measures put in place. Currently, some 10,000 such incidents are reviewed each year and rapid alerts issued whenever there is evidence of a systematic problem emerging.

This approach to incident reporting and learning mirrors some of the principles that have underpinned the dramatic improvement in the safety of civil aviation and other industries over the last three decades or more. The reporting of incidents stimulates a search for understanding on how to avoid repetition. Successful implementation encourages more frequent and reliable reporting. The number of incidents reported continues to rise: the number of serious harm events decline but further enhancements to improve safety systems continue to be developed. The whole process is fed by a recognition that safety incidents waste or damage human lives and resources. Prevention can almost invariably be demonstrated to have a positive economic impact.

Tackling healthcare safety at the frontline

One way in which high-risk industries reduce risk from rare events is through simulation. Simulation allows people to prepare for such risky events in a safe environment. It recreates conditions that closely resemble reality, while removing any danger. It means that when people confront a real emergency situation, they do so with the experience of detailed rehearsal. It is widely used in aviation and in the military. It is slowly being adopted in medicine. Simulation of rare events does not create automaticity; rather, by using simulation ‘over-learning’ occurs. People can be prepared to manage rare events without panic and disorganisation.

Most medical students now learn to take blood from a plastic arm before attempting to take it from a real arm. They learn to sew two pieces of plastic together before suturing any real skin. For these and other basic skills, simulation is now used routinely.

Simulation improves performance. Research at Imperial College London has shown that simulation improves the skills of surgeons in training. One study observed surgeons operating on pigs to remove the gallbladder. Some surgeons had received simulation training for this; others had not. Compared with surgeons who had not completed simulation training, the surgeons who had done so were twice as fast at completing the task (2,165 seconds compared with 4,590 seconds) and twice as accurate (requiring 1,029 movements rather than 2,446 movements).

Simulation reduces errors. A trial in Sweden demonstrated that junior surgeons who had been given virtual reality training for keyhole surgery made signifi cantly fewer errors than their peers who had not. Their colleagues made, on average, three times as many errors and took 58% longer to carry out an operation.

Team working: human factors

It is very rare for staff in healthcare to go to work with the intention of causing harm or failing to do the right thing. Therefore, we have to ask why there are many incidents where some of the latent conditions are caused by staff not doing the right thing, even when they know what the right thing is. Many processes and policies in healthcare are complex or seem to create diffi culties for busy staff thus creating the temptation to take shortcuts or ‘workarounds’. Safer systems tend to contain ‘redundancy’ steps – steps which may pick up an error or slip after it has happened but before it reaches the patient, therefore acting as a buffer. The cautionary note is that care is needed not to remove a step that acts as an important redundancy, having mistakenly seen it as duplication. This requires active discussion within teams, not passive acceptance.

Important as technical skills and team behaviours may be, they cannot operate in isolation of the wider organisational culture of safety that is the special responsibility of all who lead healthcare organisations. Different leadership styles can be effective, but essential components include a clear and unambiguous commitment to the paramount importance of patient safety as an essential component in the provision of high quality care, a clear connection between what leaders say and do, and what patients and healthcare workers experience at the frontline.

For a decade we have taken it for granted at the supermarket checkout that the automatic bar code reader will ensure we are charged the right price for the product we have selected and provide us with a record of the transaction. In healthcare we are still struggling to adopt and join up such auto ID technologies that are ubiquitous elsewhere. Too often, for example, we have systems that cannot ensure that the right medication is received by the right patient, at the right time, and is reliably recorded. Our failure to drive implementation of such safer technologies more actively is in part a failure of vision and of leadership. It has meant that we have passed by opportunities to improve patient safety. We need to match our ambition with action.

Key opportunities for patient safety: the new decade

It is difficult to imagine any challenge to improving patient safety greater than that we face regarding the economic realities of public investment. Leaders must have the courage to build on the evidence that better safety goes hand in hand with healthcare that is of better quality, and this can mean saving on the costs of harm (which can be very substantial). Otherwise, there will be a risk of demoting safety to a secondary consideration that may be rationed or delayed.

Over the last 10 years we have seen significant progress. There is now real momentum, with patient safety recognised as a mainstream theme of modern healthcare. Technology to help exploit opportunities for further improvements is available and developing rapidly. We need the courage to stay the course.

Sir Liam Donaldson, chief medical officer