Don’t blame clinicians

Often managers who have to deal with incidents that harm patients feel under pressure to find people responsible and be seen to act.
    
The urge to blame individuals and focus on clinical negligence could be seen as the natural response to patients being harmed in hospitals. However, is it fair to blame clinicians when the system within which they work repeatedly lets them down?

Health concerns
In industry when systems fail, they fail to safety. A nuclear power station will shut down when systems failures occur, aircraft will be grounded and underground train systems will stop running. In healthcare the system fails to danger. People are harmed when things go wrong with our system.
    
Making hospitals safer is not about focusing on clinical negligence, but about getting the systems that support clinicians’ rights. Of course we cannot discount cases of massive clinical human error, but the majority of human failings are caused by a health system that does not fully support clinicians.
    
Patients are harmed due to a cascade of small systemic errors. It is not as simple as being able to trace the patient’s adverse incident back to one specific error. If you are the clinician at the end point in this series of errors you are often the one blamed, but in fact there has been a whole raft of failings that led to the patient being harmed.
    
Julie Branter, associate director of Clinical Governance and Patient Safety at the South West Strategic Health Authority describes how a patient in her previous Trust was admitted for routine major surgery, having given his full medication history. The procedure went ahead as planned. Back on the ward the nurses reviewed his prescription chart and as he was nil by mouth did not give his usual medication. Two days later the patient experienced chest pain and was found to have suffered a myocardial infraction.         
An immediate review of the records revealed that the patient had not had his betablocker medication on the day of admission and throughout his time in hospital. Fortunately the patient made a full recovery but the omission of his normal medication undoubtedly contributed to significant avoidable harm to the patient.
    
This was not one single person or event that was at fault but a series of failures that failed the patient and harmed him. The pre-operative information sheet did not state that the patient’s existing medication needed to be continued. On admission medicines reconciliation did not take place so no one knew that the patient had not taken his usual medication and on the ward it was not routine practice to inform medical staff that medicines had been omitted due to a patient was nil by mouth.

Shared responsibility
Although we emphasise that systems let people down, this does not remove responsibility from clinical staff. It is everyone’s responsibility to make sure that the system is working correctly, once the right system is in place. Healthcare professionals should be constantly asking themselves: “What role am I playing?”
    
This is the central theme of our Safer Patients Initiative (SPI). Run through 24 UK hospitals, the emerging findings of this programme have gone to form the foundations of all four UK national patient safety campaigns. The soon-to-be-launched English safety campaign is directed by Stephen Ramsden, chief executive of Luton and Dunstable NHS Trust, one of the four UK hospitals involved in our first wave of SPI.

Practical tools
The SPI works in four clinical areas: medicines management; perioperative care; critical care; and on general wards. A focus on preventing infections is included in all of these areas. As part of the effort to make systems better in hospital the SPI has introduced a number of practical tools to support clinicians in their work and create greater reliability in systems of care
    
Julie Smith, head of Nursing at North East Wales Trust, has pinpointed differing communication styles as the root cause of poor communication between staff. The Situation - Background - Assessment - Recommendation (SBAR) tool looks to overcome this. It gives a structured format that allows essential patient information to be clearly given and then questioned by the listener with the end result of the conversation being a decision on the best course of action. It can be used when communicating in person, over the phone and also online.
    
Other tools to support clinicians include ‘early warning scores’ which allow ward staff to monitor a patient’s condition on a card that is colour coded to show when a patient’s condition is deteriorating. By picking up these warning signs clinicians can intervene earlier and work to prevent any further decline, which could, if unchecked, lead to cardiac arrest.

Important briefings
Safety briefings at the change of shifts on wards and full team briefings before surgery have also become important in ensuring that all staff know all of the necessary information about patients they will be treating. There is also a greater emphasis on systems to ensure accurate medications histories on admission.
    
This is all part of fixing the system so that it supports clinicians better. However, to make the system work all staff must be focused on safety. This is where the importance of leadership throughout a hospital is demonstrated.
    
NHS Tayside has made leadership a particular focus in its hospitals. Safety is now the first item on the executive team’s weekly meeting. They have also introduced team briefings on safety activity involving the executive and frontline staff meaning that decisions filter far quicker down their organisation.
    
Executive team members also undertake weekly structured patient safety walkrounds to meet front-line staff and hear about their safety concerns. At the end of conversations items are agreed which will be taken forward. Responsibility for acting on the concerns can be assigned to anyone present at the walkround, from the chief executive to a member of front-line staff.

Leadership
It is important that leadership on patient safety is shown from the top, but it is equally important that our view of leadership includes all healthcare professionals working in hospitals. Effective leadership on safety in hospitals challenges the very foundations of hospital culture. It means that a consultant can be questioned about why they have not washed their hands and a surgeon asked why they are late for a pre-operative safety briefing.
    
Walkrounds can also provide a greater insight into wider aspects of patient care. For example, Pete Cavanagh, chief executive at Taunton and Somerset NHS Trust, found hospital porters championing the dignity of care for patients and raising the safety issues involved in assisting patients.
    
If we want to develop hospitals that are safer for patients we need to empower the clinicians working in them to make the change. Top down edicts will not work – this is why it is so important that the four UK national safety campaigns come from the service. By focusing on the systems that let clinicians down and building the will for change within healthcare professionals by developing leaders at all hospital levels, we can go from a culture of blame to culture of collective responsibility for safety that puts the patient first.