Healthcare is a risky business. While the maxim ‘first, do no harm’ is a fundamentally important precept, and the aim of a ‘zero harm’ care environment is a laudable one, no healthcare system will ever be completely harm free. How the needs and interests of patients and professionals are managed in the aftermath of healthcare harm is therefore a significant, but largely overlooked, aspect of care quality.
Since “An Organisation with a Memory” (and perhaps before) there has been a growing rhetorical recognition in the NHS that openness; honesty and a willingness to learn from error are fundamental to the creation of a “just culture”. Regrettably, however most people still work in systems where individual blame and recrimination are the norm and where deep learning from error is still the exception.
The passive ‘concealment’ of error seems to be present at every level of the system. At the local level incidents are often not noticed or reported, especially near misses; investigations are often partial and lack any real sense of independence. Approaches to incident investigation and the tools and techniques used tend to reinforce a largely individualistic view of error. The necessary forensic skills to create good systemic descriptions of the ‘error producing’ conditions are often absent.
A lack of genuine curiosity associated with error - arguably linked with fear and anxiety about the personal, professional, organisational and political consequences - is a prevalent feature in many stories of disaster. This is bewildering for most patients and their supporters, who struggle to understand why managers and professionals would not want to understand more about how error occurs and thus how to prevent it from happening again. In short, the NHS does not have a good track record when it comes to understanding the nature of error, let alone learning from it.
The lack of understanding or learning is probably neither wilful nor deliberate; rather the conditions necessary for deep “systemic” learning are still not present in many parts of the system. In addition, it is clear that we are relying on a relatively limited set of tools to stimulate change, some of which are even reinforcing of unhelpful patterns and cultures.
Arguments around error and blame are not straightforward of course. The relationship between individual and collective professional responsibility and accountability is complex and often highly contextually specific. The issue of what is permissible and what is blame-worthy in healthcare is rarely simple.
But in the midst of this complexity there is cause to be hopeful.
Firstly, the fields’ of social psychology, medical sociology, organisational ethics, ergonomics and human factors all offer a range of sophisticated and yet practical approaches to tackling theses issues. To date, theses approaches have been largely untapped in improving healthcare at scale.
Secondly, we have increasing amounts of direct access to the “lived experience” of those who have experienced harm in healthcare, as a vital source of data and as a catalyst for change.
Thirdly, social media creates the opportunity to stimulate an uncomfortable yet crucial debate about these issues. This is a “big conversation” and I hope that these podcasts will make a contribution to the dialogue. They unashamedly explore ideas and don’t aim to provide easy solutions. What they offer is some provocation, a basis from which to start the conversation. I hope that you will all find a way to participate, whether with us or with your friends and colleagues.
Finally, can I thank all of those people who freely contributed to the podcasts and in particular to all of the families I have worked with over the years. Their courage and insights have been crucial. I’d also like to acknowledge the special contribution my colleague and long-term collaborator, Dr Suzanne Shale. Our conversations and joint research work has been pivotal to my understanding of these issues.
Prof. Murray Anderson-Wallace
To listen to the podcasts click here.