A Healthcare Community Free of Blame?

By Andy Smith, Publisher of HealthcareTrainingandEducation.com and Medical Training Magazine

Medical Training Magazine (formerly MEdSim) has long advocated the creation of a just culture for healthcare, similar to that of the airline industries ‘no fault found’ system, as the basis of long term improvement in the way healthcare is designed and delivered.

A few weeks ago, at least two Health Ministers, from the UK and Germany, endorsed such a development. Health Secretary Jeremy Hunt told an international conference in London that, “We need to ask what is blocking the development of the supportive learning culture we need to make our hospitals as safe as they should be.”

The BBC reported that this was the first patient safety conference of its kind led by ministers and as such it marks a milestone from which some direct progress might be measured. According to Hunt, the number of avoidable deaths in England was 150 a week (or about 675 a month, approximately 8000 a year). Although it was not explicitly stated that is most probably the figure for hospital care only, and is for England only not the UK.

Mr. Hunt went on to announce new measures to legally protect those staff who revealed errors and faults in hospitals, and staff supporting internal and external investigations of safety incidents. To quote the BBC report further; “the newly announced policies include a health safety investigation agency following the precedent of the Air Accident Investigation Branch.” (The AAIB is a part of the UK Civil Aviation Agency whose counterparts in the US would be the NTSB and the FAA.) “Central to this philosophy is the idea of continuous improvement and that however senior a clinician or manager may be, there is always scope to test procedures and experiment with new ways of working.”

These are much needed developments and it will be interesting to see what difference can be measured in patient outcomes in due course.

Another block to progress is how ‘error’ is defined. The airline industry, which was heavily referenced at the meeting, uses an exhaustive set of standard operating procedures and protocols to support staff, set them up for success and keep safety standards high. However, errors do occur and they are still the major cause of airline incidents. As a comparison, in 2014 39.5 million flights, carrying 3.5bn passengers, led to 12 fatal accidents with 641 fatalities - globally.  (IATA Safety Report 2014)

Unfortunately, there are very few SOP’s in healthcare and those that have been developed such as checklists, hand washing, hand off procedures and the like are far from universally employed and are often derided or ignored by those in leadership positions.

It would seem that without the supporting standard operating procedures, error, as opposed to negligence, might be difficult to determine.