From a blame culture to a safety culture: the NHS in

transition

John LilleymanMedical Director

NPSA

• Part of the UK National Health Service since 2001• Collects confidential national data on medical errors

and safety incidents• Covers England and Wales (53 million population)• Issues alerts and notices to hospitals and primary care

about safer practice• Works on designing safer systems of healthcare• Is not a regulatory or investigative body

National Patient Safety Agency

Traditional NHS culture

• Person based approach to error• The punishment fallacy

– Punishing staff when they err will make them less likely to do so

• The perfection fallacy– Staff will avoid making errors if they try hard

enough

Consequences of traditional NHS culture

• Cover up

• Close ranks

• Admit nothing

• Tell no one

• Pretend nothing happened

Barriers to moving from a blame culture in the NHS

• Changes in society• Changes in litigation• Professional silos

Society ismore fragmented and self-centred

• Family and moral values• Social behaviour• Social mores• Less influence of religion

‘In the Absence of GodBlame has become our

Prevailing religion’

Simon JenkinsThe Times 31 Dec 2004

• ‘The trouble is that having abandoned the concept of the ‘act of God’, we have also abandoned its secular equivalent – the accident’.

• ‘Having replaced them with free will and human agency, we expect that agency to perform. When it fails to do so it (someone) must be declared at fault’.

SIMON JENKINS

And the lawyers?

‘Litigation culture ischanging traditional lifestyles. Unless thegovernment actively

steps in to do somethingabout it, it could run

rampant’

Christopher Fairfax, Barrister, Tyler Law

Manslaughter:The rising tide

• 1970-1990 4 prosecutions• 1990-2004 28 prosecutions

• Conviction rate for doctors 25%• Conviction rate overall 87%

Increase in manslaughter charges for doctors due to

• Change in CPS attitude to gross negligence or recklessness at work in 1990s

• Growing social intolerance of medical errors

‘Gross negligence’ manslaughter has 4 components

• Duty of care to the deceased existed• That duty was breached• Death was caused by that breach of duty• Breach was so great as to be considered gross negligence

and therefore a crime

Richie Williams

Dr Murphy Dr Lee

Latent errors in vincristine case

• Not starved, put to end of list• Wrong ward, inexperienced nurses• Drugs taken to theatre together• Rest of list finished, doctor i/c had to leave• Anaesthetist assured procedure straightforward• Prescription difficult to interpret

NASOGASTRIC TUBE ERROR

Hiral Hazari aged 23 in first PRHOjob charged with killing by failing tonote NG tube misplaced in lung. Youngest doctor charged so far.

Katherine O’Reilly died from lung damage

More Luer troubles

Dr Falconer fatally injected air into an IV line instead of an NG tube during surgery for pyloric stenosis on Aaron Harvard aged 6 weeks.‘A broken man’, he was acquitted.

Features of recentmanslaughter cases

• All of the doctors intended to help patients• All were victims of system failures• All were devastated when faced with what they had

done• ‘Recklessness’ is hard to identify in the media reports• Institutional learning not shared

Systematic failures(Reason’s ‘latent pathogens’)

• Weak safety culture• Inadequate operational practices• Lack of explicit protocols• Lack of experience/training• Communication failures• Poor equipment design

Professional silos

silo noun (pl. -os)

• 1 a tall tower or pit on a farm used to store grain. n a pit or other airtight structure in which green crops are compressed and stored as silage.2 an underground chamber in which a guided missile is kept ready for firing.ORIGIN mid 19th cent.: from Spanish, via Latin from Greek siros ‘corn-pit’.

MDTs

• Change ‘climate of blame, acrimony and confrontation’

BUT HOW TO CHANGE?

• EDUCATION– Understand why and how people err– Recognise healthcare as a high risk industry

• Work in teams• Report and learn• Aspire to open and fair culture, not no-blame• ‘Making Amends’

– System of redress

Engage the professions

• ‘Changes in process, structure or policy that are supported and driven by the clinical workforce are far more likely to achieve lasting success than those perceived to be imposed on service providers by a distant administration’.

– BAMM 2005

Be patient

• Cultural change takes time• It proceeds patchily with hares and

tortoises• It requires leadership and enthusiasm

What goes around comes around

‘It still tastes awful’