ASPiH UK Day 2 Speaks to Safety in Healthcare & Lessons from the Aviation Industry
Today in Brighton UK, day 2 of the Association for Simulated Practice in Healthcare annual meeting was kicked off by Peter McCulloch Professor of Surgery at the University of Oxford, and co-director of the Patient Safety Academy, who spoke on safety in healthcare.
He started by sharing his indoctrination as a surgeon in the 1980s with strict guidelines and responsibilities, especially after errors. He found in reality though blame is rarely accepted and incorporated. Peter then reminded us of several major accidents which demonstrated a common theme: that error occurs in multiple areas before disaster strikes reflecting:
- There was no “root cause”, there was multiple causes.
- There was no single person who acted outrageously
- The contributing factors were very varied
- Miscommunication and confusion about responsibility
- Extraneous stressors impacting on judgements
He suggested that “the tip of the iceberg is not the most important part, the cumulative risk rises as a function of independent errors.” How then, do we prevent errors? Peter suggests we need to look not at salient points but as the system as a whole. This requires us to rationalize work systems with risk designed out, continuous monitoring with instant feedback on error, a trained and motivated workforce, and systems for ongoing evolutions of improvement changes. While difficult to provide, such explorations will provide clarity of responsibility, resilient workforce, standardized of work systems, and additional measurement tools.
- Feedback – Given rapidly, specifically, and accurately. As well, it can be incentivized by anonymous competition, but must be supported opportunities to improve.
- Checklists – promote clear structured communication but need to be co-designed by an educated workforce.
- Team work training – Promoting culture and effective communication
- QI – Utilizing a lean model for continual improvement adjustments.
Peter’s team has done research which has demonstrated dramatic results when crm and lean qi were combined as intervention. Challenges that remained for improvement were lack of time, space, expertise, attitudes, and management buy-in.
He concluded that we need an implementation strategy for change management when trying to improve healthcare education which includes diffusion of innovations, advertising psychology, interpersonal strategy, and incentives for change. He closed reminding us what simulation can do here: technical training, non-technical skills training, crisis proofing, and training in QI.
Afterwords, Dr Stephen Shorrock, European Safety Culture Programme Leader at EuroControl spoke on European Air Traffic Control, A High Reliability Industry
Stephen suggested that the notion of safety culture emerged from the Chernobyl nuclear accident in 1986, and has resulted in a mass of research and practical interventions, both small and large, in many industrial sectors. Recent thinking has, however, been increasingly critical of the concept and the value of safety culture research and practice. At the same time, practitioners’ experience on the ground is that the concept remains useful and relevant for various practical reasons. The middle ground may be that our ideas about safety culture need to adapt, both theoretically and practically, in several ways. This talk explored the notion of cultures of safety, outline some traps in safety culture work, and reflect on practical experience gained from over 30 European countries, from one of the world’s biggest safety culture programmes.