Final Report > Chapter 26: The Safety of Care > The components of safe care

The components of safe care

4 The individual healthcare professional's ability to do what is proposed with proper competence and skill is, of course, crucial in ensuring safe clinical care. But professional competence is only part of the picture. Good people, with good skills and good intentions, sometimes make mistakes. How can this happen? To begin to answer this question, we need to understand that healthcare professionals work in a system. They work in NHS buildings and make use of equipment and drugs provided to enable them to care for patients. Any number of these surrounding factors, or latent conditions, can give rise to error. A misalignment of switches on a ventilator, an instrument which shows a false reading, or the unclear labelling of drugs, can have grave consequences for the safety of patients. As we saw in Bristol, the organisation of care in two separate buildings for seriously ill children undergoing high-risk surgery had serious consequences for the safety of the children and the outcomes of their care.

5 Working arrangements, as well as the physical environment, also influence healthcare professionals' performance. Most now work in teams of varying kinds. To function effectively in support of patients, teams need to be well led and there must be good communication, both within and beyond the team. If the team does not work well together, if it is not well-led or if communication is poor, the safety of the patient is compromised. Healthcare professionals also work under the pressure of long hours and heavy demands. Evidence from other sectors in which professionals handle complex information and make decisions under pressure, such as in the nuclear and airline industries, suggests that such pressures, if not properly managed, can affect an individual's judgment even when faced with routine tasks, thereby jeopardising the safety of others. All of these factors can have a bearing on the safety of clinical care, no matter how dedicated or competent the healthcare professional may be. The potential impact of these surrounding factors, when combined together, was summed up well by Professor Lucian Leape, drawing on Professor James Reason's work:

`... accidents in complex systems occur primarily through the concatenation of multiple small factors or failures, each necessary but only jointly sufficient to produce the accident. Often these small failures or vulnerabilities are present in the organisation long before an incident is triggered.' [6]

To translate this general principle into something recognisable to all: what airline would ask a co-pilot to be in the cockpit, let alone have to land the plane after being on duty continuously for 24 or more hours? Yet, hospitals routinely still expect junior doctors to be on call (or on duty) and to care for ill patients in such circumstances, notwithstanding, indeed by virture of, the current arrangements made in light of the European Working Time Directive. [7]

Footnotes

[6] Leape L, et al. `Promoting Patient Safety by Preventing Medical Error' (editorial). `Journal of the American Medical Association' 1998; 280 no. 16

[7] 93/104/EC. And see HSC 1998/240