Final Report > Chapter 26: The Safety of Care > Creating a culture of safety

Creating a culture of safety

14 Placing the safety of patients at the centre of the hospital's agenda is the crucial first step towards creating and fostering a culture of safety. This means that safety must be everyone's concern, not just that of the consultant, or the nurse in charge. Even less should it be represented as being solely the concern of a person bearing a title such as `Safety Officer' or `Clinical Risk Manager'. That merely succeeds in giving the impression that safety is for `someone else' to look after and that, somehow, the issue has been appropriately dealt with. The safety of patients, the safety of their clinical care, is a matter for everyone, from the trust boardroom to the ward assistants. Safety requires leadership from the highest level of management. It requires constant vigilance. It should be considered in everything that the organisation does. It is not a short-term project but a commitment for 365 days a year. A culture of safety can only really be created when a concern for patients' safety is embedded at every level of the organisation.

15 Central also to a culture of safety is an understanding that adverse events occur and that people and the organisations of which they are part do make mistakes. To err is human. A culture of safety, therefore, is one that seeks not so much to eliminate as to analyse and thereby anticipate adverse events including errors and, in the light of that analysis, to organise systems and practices which, as far as possible, prevent them. Some types of adverse event can be eradicated, of course, and when this is possible it must be done. Others cannot, but their impact can be substantially reduced. Barriers or defences can be built into systems so as to help avert them, or to contain and mitigate their potential for harm. As Professor James Reason suggested at one of our seminars: `Though we cannot change the human condition, we can change the conditions under which humans work.'

16 Constant vigilance is, therefore, a feature of a culture of safety. This point was made forcibly by Professor Marc de Leval, Professor of Cardiothoracic Surgery, Great Ormond Street Hospital for Children NHS Trust. There is, he said, a need for a pervasive mindset of chronic unease, or intelligent wariness. [18] This is not the same as encouraging fearfulness. The line between them is fine, but the latter must be avoided. It raises defences and can easily lead to paralysis. Organisations which adopt an attitude of vigilance do not assume that `no news is good news'. They recognise that `no news is in fact no news'. They are thus more likely to be on the lookout for errors and consequently are better prepared to respond when an incident does occur. On this analysis, it is important that people are aware of what they do not know, are aware of where danger may lie, know what should not happen and what is unacceptable, know what to do when problems are identified and know that these will be handled quickly. As the Secretary of the US Anaesthesia Patient Safety Foundation wrote recently: `The price of patient safety is eternal vigilance'. [19], [20]

17 Perhaps the most fundamental feature of a culture of safety is the need for the hospital to create an open and non-punitive environment in which it is safe for healthcare professionals to report adverse events, safe to admit error, safe to admit when things have almost gone wrong, and safe to explore the reasons why. Adverse events, especially clinical errors, very often go undetected and unreported because of fear: the fear healthcare professionals have of being blamed and perhaps more fundamentally, the fear of what it will mean for them to acknowledge that through their conduct a patient has actually been harmed, the last thing they intended. This goes beyond a fear for job or reputation. The sense of apprehension was captured by Albert Wu, writing in the special edition of the `BMJ' on medical error:

`... although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors; they are the second victims. Nurses, pharmacists and other members of the healthcare team are also susceptible to error and vulnerable to its fallout. Given the hospital hierarchy, they have less latitude to deal with their mistakes: they often bear silent witness to mistakes and agonise over conflicting loyalties to patient, institution and team. They too are victims.' [21]

Without a culture of safe reporting, it will be impossible systematically to collect information about the incidence of adverse events, especially errors. Without knowing what is going on, no organisation can take a valid view on how safe it is for the patient to be there, far less take any necessary corrective action. Without knowing, there can be no learning. Without learning, there can only be the risk that it will happen again.

18 The essential features of a culture of safety are, therefore:

• Concern for the safety of patients should be embedded in the NHS as a whole, and be the responsibility of everyone who works in a trust.
• There must be an awareness and understanding of safety and an appropriate means of managing issues relating to safety at all levels of the NHS.
• Human fallibility is an inescapable reality: thus, systems are needed to anticipate all types of adverse event, to eradicate them where possible and mitigate their effects.
• A mindset of constant vigilance is crucial.
• Fear is the enemy of safety: an open and non-punitive environment, in which it is safe to admit and report adverse events, especially errors, is fundamental.
• Adverse events offer an opportunity to learn and to make changes for the better, not an occasion merely to punish and forget.

Footnotes

[18] See report of Seminar 6, Annex B

[19] Gaba DM. `Anaesthesiology as a Model for Patient Safety in Health Care`. `BMJ' 2000; 320: 785-8. www.bmj.com

[20] The metaphor of the `squirrel on the lawn' was suggested at a Phase Two Seminar: even at the time when all appears safe, the squirrel remains ever vigilant

[21] Wu AW. `The Doctor Who Makes Mistakes Needs Help Too'. `BMJ ` 2000; 320: 726-7. www.bmj.com