Nobody is perfect and we all make mistakes. In health care some degree of error is inevitable. Care is a multifaceted process often involving complex procedures, treatment regimens and equipment. We are dealing with human interaction and the exercise of human skill and judgment. The best we can hope to do is to try to minimise the risk of error occurring, to be risk aware, to learn from the patient safety errors of past and to change practices. These are the fundamental prerequisites for developing an ingrained patient safety culture in the NHS.
There is no shortage of reports showing patient safety incidents from a variety of national organisations such as the Care Quality Commission (CQC) and NHS Resolution, and international organisations such as the World Health Organiztion (WHO). The difficulty for the nurse and doctor is to keep track of all this information in challenging working environments—and to work out which is the most authoritative and relevant information.
‘Staff are struggling to cope with large volumes of safety guidance, they have little time and space to implement guidance effectively, and the systems and processes around them are not always supportive. Where staff are trying to implement guidance, they are often doing this in addition to a demanding and busy role. This makes it difficult to give this work the time it requires.
Patient safety is now a large national and global service industry with many organisations producing reports and advice. It will be interesting to see how well the NHS patient safety strategy (NHS England and NHS Improvement, 2019) meets this challenge after the COVID-19 pandemic subsides, which has understandably delayed development progress. The strategy maintains a lot of potential through the national patient safety syllabus to develop effective teaching and learning strategies.
Global Patient Safety Action Plan
WHO has recently produced a third draft of its Global Patient Safety Action Plan 2021-2030 (WHO, 2021). This is an important publication because it helps set the global agenda for patient safety. Its themes can usefully guide and inform countries national patient safety policies and development. provide a list of suggested actions for a variety of stakeholders ranging from policymakers to health care workers. These are the underpinning guiding principles or values that guide the development and implementation of the WHO plan (WHO, 2021: section 3):
Linked to these underpinning values, WHO (2021) provides a framework for action that includes seven strategic objectives, which can be achieved through 35 specific strategies. The objectives include:
‘Strategic objective 1. Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere.’
This objective provides an excellent focus on patient safety and acts to balance, counter the inevitability of error argument discussed above. The practical reality is that even though some degree error is inevitable in healthcare delivery, we can adopt a healthy patient safety mindset to always work to a zero tolerance of it.
Never Events
The latest Never Events figures (NHS England and NHS Improvement, 2021) provide an invaluable, although chilling, source of patient safety teaching and learning material showing adverse healthcare events. Events that should never have happened in our NHS, but which stubbornly persist.
Never Events are defined in the report as serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. The report shows 226 serious incidents appeared to meet the definition of a Never Event in the Never Events list and had an incident date between 1 April 2020 and 30 November 2020. This provisional number is subject to change as local investigations are completed. The type and number of incidents that occurred are listed and include:
Delving into more detail, some of the wrong site surgery Never Events include:
In one sense, reading the Never Events reports it seems that they are wrongly titled. The epithet ‘common never events’, seems much more appropriate. These types of events should not be happening in a modern-day NHS developing a system-wide patient safety culture. The fact that they continue to happen speaks volumes about progress in developing a safety culture.
Local news as a source of reports
There are many sources of reports of adverse healthcare events that can inform teaching and learning in patient safety. These can range from national reports such as those by NHS England and NHS Improvement, to local and national newspapers that cover such events. For example, the Shropshire Star recently reported on a Coroner's inquest into the death of Mohammed Ismael ‘Bolly’ Zaman, 31, while he was being treated at Royal Shrewsbury Hospital:
‘Pharmacy dispenser Bolly, who had suffered a number of health problems due to being a Type 1 diabetic, died after an unidentified nurse pressed the “reset” button on his dialysis machine when the alarm went off, without checking the tubes were connected. He lost three pints of blood in 7 minutes, went into cardiac arrest and died on October 18, 2019.Bolly's family are suing the hospital for the part staff played in his death.’
CQC inspection report
In terms of teaching and learning aids on patient safety, the CQC's inspection reports provide a rich and detailed source of material. These are frequently published and reveal both good and bad healthcare practices. The CQC has recently published reports following two inspections at Liverpool University Hospitals NHS Foundation Trust (CQC, 2021). The CQC has told the trust to take immediate action to improve the safety of some of its services. Several key patient themes can be seen in the reports. Findings included:
CQC reports do provide deep dives into patient safety in hospitals and other organisations and are excellent teaching and learning aids.
Considering the harm to staff
The National Learning Reports of the Healthcare Safety Investigation Branch (HSIB) are essential reading for patient safety learning and education. A recent report has focused on support for staff following patient safety incidents (HSIB, 2021).
When analysing adverse patient safety incidents, the focus must be on the injured patient, helping them, finding out what happened and satisfactorily resolving matters. However, the incident will also impact on others:
‘The patient is the person most directly harmed following an incident, but harm can also occur to others. These include the patient's family, healthcare staff who have cared for the patient, those who investigate the incident and the organisation where the patient was treated. Staff may experience emotional distress or wellbeing issues as a result of patient safety incidents. They may also sustain a moral injury which is “the psychological distress which results from actions, or the lack of them, which violate someone's moral or ethical code”.’
HSIB provides insights on supporting NHS staff after patient safety incidents. It also presents key principles in the area and gives examples of best practice.
Conclusion
This column began with the stark proposition that some degree of error in health care is going to be inevitable. That the best we can do is to work from a zero-harm mindset and try to minimise the risk of harm occurring. To effectively manage risk.
There are no shortages of reports from a vast array of patient safety stakeholders, nationally and internationally telling us how to do this and reporting on errors made. This information is to be welcomed as patient safety is an acute issue of national and global concern. The problem remains however on how to manage, filter and apply this rising tide of patient safety information?
Worryingly, never events can be seen to be a perpetual NHS patient safety problem highlighting the urgent need for health professionals to learn the lessons that emanate from them.