Professional engagement The big safety challenge John Lilleyman Medical Director NPSA

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Professional engagement The big safety
challengeJohn LilleymanMedical DirectorNPSA
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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

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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

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Consequences of traditional NHS culture

• Cover up
• Close ranks
• Admit nothing
• Tell no one
• Pretend nothing happened

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Barriers to moving from a blame culture in the NHS

• Changes in society
• Changes in litigation

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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
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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

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Richie Williams
Dr Murphy
Dr Lee
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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

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Systematic failures(Reasons latent pathogens)

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

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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

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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
• Non-adversarial system of redress

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Above all 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

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NPSA Professional Advisory Panels

• Medical
• All specialties
• Nursing and Midwifery
• Allied Professions and Healthcare Scientists
• Pharmacists, phisiotherapists and physicists

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Be patient

• Cultural change takes time
• It proceeds patchily with hares and tortoises
• It requires leadership and enthusiasm

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