Final Report > Chapter 26: The Safety of Care > The components of safe care > Past and present approaches to clinical safety

Past and present approaches to clinical safety

9 Until the recent past, very little attention within the NHS was given to the wider, organisational context of clinical safety, or to the relationship between a healthcare professional's actions and the work environment. The tendency was, and to a large extent still is, to see safety in negative terms. The focus was on those adverse events which had the most serious outcomes - death and disabling injury - and on the more egregious examples of a healthcare professional's conduct: in other words, to look at individual cases and for singular causes, for which someone could be found to blame. There was no place in this approach for seeking to understand the cause of the event, to learn from it, and to share that learning so as to avoid similar events in the future. Instead, there was the false assumption, that, when something went wrong, invariably it was caused by a negligent or incompetent individual. What we now know, and must understand for the future, is that adverse events in healthcare, as elsewhere, are very often caused by a much wider range of factors.

10 At the level of the hospital, again until the recent past, `safety' as an issue would not commonly have been understood as being concerned with clinical care. It had much more to do with non-clinical matters, such as the means of escape in the event of a fire; the safety of procedures to deal with hazardous materials; and the protection of patients from such harm as slipping on wet floors, or falling out of bed. In this regard, the evidence from Bristol is striking. Throughout the whole of the period of the Inquiry's Terms of Reference, the guidance in force on the reporting of accidents and untoward incidents was still that issued by the Ministry of Health in 1955. The majority of all of the incidents recorded in the incident logbooks for the cardiac wards in Bristol relate to non-clinical events, such as falls and inadvertent self-harm. This is how the safety of patients was regarded, and to a degree still is, not just in Bristol but generally. We were informed by Mr John Gray, Manager of Legal Services at the UBHT, that there was no formal policy or mechanism which required incidents to be reported or investigated, far less for the lessons to be learned and shared. For serious `near misses' or major accidents, the UBH/T did, however, have an informal system for reporting based on professional judgment. In adopting this approach to patients' safety, the UBH/T, according to Mr Gray, was not unusual. It was doing no more than following standard practice at the time. Mr Gray stated that there was `... much less emphasis on written procedures than there is today, but it would be wrong to interpret lack of a formal record as indicating lack of attention or lack of action where these were obviously necessary. [13] ... In effect, staff operated to unwritten protocols where matters such as the reporting of accidents and untoward occurrences were standard practice and fundamental.' [14]

11 One relatively recent initiative, at least as regards adverse events which amount to clinical negligence, is the clinical negligence scheme for trusts put in place by the NHS Litigation Authority (NHSLA). [15] The aim of the clinical negligence scheme is to reduce the incidence of events leading to claims for compensation, by pressing trusts to develop their systems concerned with clinical risk and safety. Trusts now pay annual premiums to the NHSLA. They are offered financial incentives in the form of discounts on premiums if certain standards are met (such as standards in relation to the trust's policies on risk management, on health records and on its response to major clinical incidents). While this arrangement is undoubtedly sensible, in that it constitutes an incentive for trusts to be more active in protecting patients, we note that the incentives, in terms of the discounts on premiums, are relatively small. We note further that the bulk of payments for clinical negligence are still met directly by the NHSLA, thus insulating trusts from the full financial impact of error. We also note that, to the extent that there are incentives for improvement, they are purely financial. While these are of concern to those involved in senior management, it is unlikely that such signals are relevant to those healthcare professionals involved in the day-to-day care of patients.

12 In their recent report the expert group chaired by the Chief Medical Officer (CMO) stated that: `The NHS is failing to learn from the things that go wrong and has no system to put this right.' [16] The NHS is only now at the early stages of creating a systematic mechanism for identifying, analysing, and learning from adverse events, with a view to reducing or preventing errors in the future. Much of the information required to help to prevent adverse events, as a result of which patients are harmed, is either not collected at all, or is to be found in a patchwork of over 1,000 unconnected and different systems. The very few national systems which do exist, such as the National Confidential Enquiries, and the reporting systems of the Medicines Control Agency and the Medical Devices Agency, work in isolation from each other and are limited in their scope. Thus, the capacity of the NHS to analyse the causes of adverse events, to make known the lessons learned and to embed those lessons within the systems and practices of care, is extremely limited.

13 Clearly this must change. The CMO's report was a seminal and important step along that road. We strongly support and endorse the thrust behind the expert group's recommendations, principally that there should be: a unified system for the reporting and analysing of adverse events; a more open culture in which errors can be brought to light; and a system for ensuring that lessons are learned and practice is changed to reduce the incidence of errors in the future. We note the decision to implement the report's recommendations through the creation of a National Patient Safety Agency. [17] Since the agency is not yet in operation, we confine ourselves here to commenting on the CMO's report, not least since the agency's purpose is to act on the report. We will, however, make one point of general importance. We note the tendency of government to respond to issues by creating new bodies or institutions. While sometimes justified, there is always the danger that the creation of the institution is seen as an end in itself; that by its creation the problem is solved. Furthermore, it is a central message of this report that in the past the NHS has suffered from too many bodies acting independently, with no overarching integration and co-ordination. We agree with the main direction of the CMO's report. We believe, however, that its recommendations should go further. If the full implications of Bristol are to be grasped, more change and of a more radical nature will be needed. In the remainder of this chapter, we set out what form that change might take:

• We believe that more attention must be given to establishing a proper baseline of knowledge about the extent and nature of adverse events and near misses in the NHS; without this we will never know in the future if improvements have been made.
• We make some observations on the Department of Health's (DoH's) proposed new system for reporting of adverse events and near misses.
• Reporting of error is crucial to the improvement of safety. We consider in depth how to tackle two major barriers which stand in the way: the current focus on blame and the recourse to clinical negligence litigation. The experience of reporting systems used in some US hospitals and in the aviation industry are instructive.
• We argue for a higher profile to be given to design-led solutions to tackle some of the underlying causes of error.
• We consider the importance of fully integrating safety into clinical governance and the external review of trusts.
• We emphasise that the starting point must be the need to create a culture of safety, so we consider this first.

Footnotes

[13] WIT 0137 0028 Mr Gray

[14] WIT 0137 0029 Mr Gray

[15] The NHSLA was set up in 1995. Through its clinical negligence scheme for trusts, it pools the costs of trusts' liabilities for clinical negligence arising from incidents occurring after 1 April 1995

[16] Department of Health. `An Organisation With a Memory: Report of an expert group on learning from adverse events in the NHS'. London: DoH, 2000

[17] The creation of this agency was announced in April 2001.'Building a Safer NHS for Patients'. Department of Health. www.nhs.org.uk