Patient safety
Amongst the welter of changes being urged upon the NHS, one of the more
encouraging is the increasing emphasis on safety, both for patients and for
staff. There is of course a whole range of reasons why this should be so:
health and safety regulations are not only widening in scope, but also being
more comprehensively (if not always more sensibly) enforced. The increasing
readiness to engage in litigation both stimulates and provokes greater care
(if only of a defensive nature). These goads to action are, however, in a
very real sense incidental. What is important is for the culture to change,
and for those who mould the culture to want the change to happen. It is here
that the dilemma lies. Within the system — indeed amongst us all — there is
an understandable fear of revealed failure and of blame for shortcoming.
In his evidence to a United States Senate subcommittee, Dr Lucien Leape,
one of the world’s leading experts in this field, said: “Errors are seldom
due to carelessness or lack of trying hard enough. More commonly, they are
caused by faulty systems, processes and conditions that lead people to make
mistakes. They can be prevented by designing systems that make it hard for
people to do something wrong and easy to do it right ... A punitive approach
shuts off the information that will identify faulty systems and create safer
ones. In a punitive system, no one learns from their mistakes.”1
This issue of the Journal examines four different aspects of the
learning rather than the punitive approach to error. Following the Chief
Medical Officer’s Report on Patient Safety, the National Patient Safety
Agency (NPSA) was created in July 2001 to devise and run a national
data-collection system from which to perceive safety problems and to devise
solutions to them. An example of this approach is reported elsewhere in this
issue, and shows the positive results that followed co-operation between the
Agency and four major suppliers of GP-computing systems.
In his article, Clive Flashman, Head of Knowledge and Information
Management, NPSA, describes the newly developed National Reporting and
Learning System, which will enable NHS organisations to report
electronically on adverse incidents, drawing on organisations’ existing
risk-management systems. This approach offers the potential to support a
healthcare community that is prepared to learn from its mistakes and to
devise ways of preventing them for the future, rather than staying in a
punitive mode, cloaked in secrecy.
Our second article also comes from the work of the NPSA. Chris Ranger,
the Agency’s Assistant Director of Safety Solutions, explains the background
to the recent Patient Safety Alert that recommended the standardisation
across the NHS of the crashcall number — the internal telephone number used
to mobilise a hospital’s resuscitation team. With an increasing use of locum
and agency staff and the rising numbers of staff from within the European
Community, there are obvious dangers in the use of different crashcall
numbers across the Service: hesitation about what number to call may well
lose seconds, seconds that are potentially vital to a patient’s life. This
is a practical example of a simple system change that can positively improve
patient safety.
Our third article exemplifies the approach of examining a series of
adverse incidents, deducing the lessons that can be learnt from them, and
devising a system that improves practice for the future. In the wake of the
Kennedy Inquiry into neonatal cardiac care at Bristol Royal Infirmary, the
NHS Information Authority and the Healthcare Commission have jointly funded
the UK Central Cardiac Audit Database (CCAD), a national audit system for
cardiovascular disease, including congenital heart disease. All 13 UK
specialist heart centres contribute to the database, now entering its fourth
year of operation. In addition to monitoring and comparing performance, in
the longer run the CCAD will have the ability to track re-intervention,
wherever it occurs within the UK — a powerful tool in evaluating the
efficacy of different approaches to treatment.
Our final article covers yet another aspect of improving patient safety.
Amongst the initiatives within the National Programme for IT is the drive
for an integrated care record. An essential component of that record has to
be a standard coding system for medicines and personal medical devices. In
their article, Paul Frosdick and his colleagues describe the collaborative
work in progress between the NHSIA, the Prescription Pricing Authority and
others to achieve such a code. Without it, much of the potential benefit to
be derived from an integrated record cannot be realised: in particular, the
variety of ways in which a similar prescription can be described offers a
certain potential for misunderstanding and error.
As our articles show, there are many ways to improve patient safety, but
they have to be achieved by a dispassionate examination of the facts and a
willingness to learn, not by a punitive environment.
Michael Fairey
Reference
1. Leape L. Testimony to the US Senate Subcommittee on Labor,
Health and Human Services, and Education, concerning patient safety and
medical errors. 25 January 2000.
www.apa.org/ppo/issues/sleape.html (accessed May 2004) |
