Dear HIFA colleagues
On Monday this week a doctor shared a tragic safety episode of a time early in their career in 1986 when a missed diagnosis of epiglottitis (a very rare condition) had a tragic outcome. They told us that the memory of this event can still distress them decades later and reflected with hindsight on the many systems factors that contributed to the problems that occurred. They received no real support after the event and were expected to treat it as 'one of those things'. This was indeed the understanding of error and harm that was common at that time when I was working on errors in medicine as a researcher in an emergency department. We now understand that the great majority of events that harm patients have a much more complex set of causes and contributory factors.
The person who helped me and many others understand the nature of error was James Reason, a British Psychologist who wrote widely on human error and safety. This elegantly written quotation beautifully summarises one of his key insights:
"Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking."
People of course play a part when things go wrong, but they are simply the final link in the chain, the final garnish to a lethal brew as Jim Reason memorably says. Clinical staff are often 'set up to fail' by the systems they work in, as the story of the missed diagnosis showed us.
There is also now, thankfully, a great deal more understanding of the impact of error and harm on patients, families and healthcare professionals though blame and recrimination are still far too common. Some organisations have active programmes to support all concerned after serious events.
People sometimes write and say that we are making little progress on patient safety. We are certainly not making us much progress as many people hoped. However, when I think back to the attitudes and understanding of the 1980s and compare that with today, it is clear that our understanding and approach to safety in healthcare has completely transformed.
I thank the person concerned for sharing their story with us this week, for teaching us about safety through their story and offering hope and support to the many, many other HIFA colleagues who will have had similar experiences.
Charles Vincent
HIFA Spotlight on Patient Safety and NCDs
HIFA profile: Charles Vincent trained as a clinical psychologist and worked in the British NHS for several years. Since 1985 he has focused on conducting research on the causes of harm to patients, the consequences for patients and staff, and methods of improving the safety of healthcare. charles.vincent AT psy.ox.ac.uk