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From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA

From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA. National Patient Safety Agency. Part of the UK National Health Service since 2001 Collects confidential national data on medical errors and safety incidents

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From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA

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  1. From a blame culture to a safety culture: the NHS in transitionJohn LilleymanMedical DirectorNPSA

  2. National Patient Safety Agency • 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

  3. 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

  4. Consequences of traditional NHS culture • Cover up • Close ranks • Admit nothing • Tell no one • Pretend nothing happened

  5. Barriers to moving from a blame culture in the NHS • Changes in society • Changes in litigation • Professional silos

  6. Society ismore fragmented and self-centred • Family and moral values • Social behaviour • Social mores • Less influence of religion

  7. ‘In the Absence of GodBlame has become ourPrevailing religion’ Simon Jenkins The Times 31 Dec 2004

  8. ‘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

  9. And the lawyers? ‘Litigation culture is changing traditional lifestyles. Unless the government actively steps in to do something about it, it could run rampant’ Christopher Fairfax, Barrister, Tyler Law

  10. Manslaughter:The rising tide • 1970-1990 4 prosecutions • 1990-2004 28 prosecutions • Conviction rate for doctors 25% • Conviction rate overall 87%

  11. 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

  12. ‘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

  13. Richie Williams Dr Murphy Dr Lee

  14. 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

  15. NASOGASTRIC TUBE ERROR Hiral Hazari aged 23 in first PRHO job charged with killing by failing to note NG tube misplaced in lung. Youngest doctor charged so far. Katherine O’Reilly died from lung damage

  16. 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.

  17. 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

  18. 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

  19. Professional silos

  20. silonoun(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’.

  21. MDTs

  22. Change ‘climate of blame, acrimony and confrontation’

  23. 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

  24. 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

  25. Be patient • Cultural change takes time • It proceeds patchily with hares and tortoises • It requires leadership and enthusiasm

  26. What goes around comes around ‘It still tastes awful’

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