Written by Andy Smith, MTM publisher

The British Government published a Joint Committee report on 2 August 2018 regarding the establishment of a Health Service Safety Investigations Body.

Intended to create a ‘legal safe space’ so that “anyone involved in the delivery of care can speak openly is crucial if the health system is to learn from its mistakes,” stated Bernard Jenkin MP, Committee Chair.

He went on to say: “When serious incidents take place patients have a right to find out what went wrong and staff need to feel that they can be open without being blamed or made a scapegoat. Poor quality investigations fail to address the concerns of patients, breed mistrust amongst healthcare professionals, and do not help make care safer. Putting the HSSIB on a statutory footing to conduct independent safety investigations will help address each of these concerns.”

In 2015 the U.K. estimated that 12,000 avoidable hospital deaths occur each year and in England alone there are 24,000 serious incidents and 1.4 million low-harm or no-harm ‘near misses’ annually. For comparison, the population of England is 54 million and that of the UK as a whole 67 million. U.K. comprises England, Scotland, Wales, N Ireland, and each manages its own healthcare service.

This initiative, which may be a world first, could potentially be comparable to the U.K.’s Air Accidents Investigation Branch, French BEA and the U.S. NTSB in that it would presumably result in care and training recommendations as a result of incident investigation. Certainly all aviation incident investigations result in training improvement recommendations because, as with healthcare, Human Factors are usually a major element in all incidents.

Two recognizable airline terms have begun to intrude on the healthcare space and into thinking on healthcare performance improvement. Human Factors (HF) is one and CRM, in this case Crew Resource Management, the other. In simple terms HF begins with the acceptance, or expectation that errors will be made (to err is human) and designs procedures and safety systems to foil them. James Reason’s Swiss Cheese Theory is worth reading for some of the thoughts underpinning this approach.

CRM can be thought of as assuring that the full resources of the team are deployed and utitlised in safe completion of the ‘mission’. Assigning specific tasks to each team member and working to establish a communications protocol to ensure all are heard and concerns are taken into account, the team works within a protective cocoon of safety procedures established by the operators and regulators to ensure that, if at all possible, errors are avoided. Should the worst happen and an incident does occur, the crew are held harmless assuming all protocols have been followed.

The system however is held to account and improved if found that it is needed.

It is a system that healthcare needs to establish if it is to reduce avoidable error, improve outcomes and reduce waste. TEAM STEPPS was designed to take CRM into the healthcare environment. Regrettably, as is usual in healthcare, critical team members are often missing from TEAM STEPPS exercises as these training exercises are not mandatory.

Whilst choice and voluntary good behaviors seem laudable, they have not led to safe, cost-effective and efficient healthcare provision and the individual is open to lawsuits as a result.

For more: https://www.parliament.uk/business/committees/committees-a-z/joint-select/draft-health-service-safety-investigations-bill/news/health-service-safety-investigations-bill-report-published-17-19/

Professor James Reason: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1298298/

Clinical Human Factors Group: https://chfg.org/

CRM in Healthcare: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488012/

For airline training updates: https://civilaviation.training