Memorandum by Dr Jeffrey C McILwain (PS
1. WHAT THE
Role of human error and poor clinical
judgement. Human error and clinical judgement are synonymous.
A "poor" judgement is influenced as much by the professional's
poor judgement as the presentation by the patient. If the patient
leads the clinician down the wrong path in the history, within
limited NHS time resources the clinician has little time to correct
this. Humans do not fit mathematical modelling except at the macro
level ie populations, not individuals.
Systems failures. There are only
three things that can go wrong in life:humans, systems
and equipment. The first designs and controls the latter two,
therefore all systems failures are human at source. System design
can work if the system is tested to an extreme. This is a standard
engineering principle. If one component fails then the whole system
may fail eg `O' ring test failure in the Challenger space shuttle
disaster. After extreme testing then monitoring has to take place.
Further, is the issue of standardisation. The Great Western Railway,
as an example of standardisation, greatly brought forward safety
and production by standardising and interchanging parts. There
are no tested nor standardised safety systems within the NHS except
within purchased equipment.
How far clinical practice can be
risk-free; the definition of "avoidable" risk; whether
the "precautionary principle" can be applied to healthcare.
Clinical practice never has, and never will be, "risk free".
Industries such as the petrochemical, rail or air industries have
shown that despite improvements and "lessons learned"
there are still risks either apparent and unsolvable or latent.
The role of public perceptions of
risk in determining NHS policy. Perception is a frailty built
upon notions or opinion not fact. No fact = no science. No science
= no measurable commodity.
2. WHAT THE
a. local and regional NHS bodies, and other
organisations providing NHS services (including primary and community
care, and mental health services)
How far the Boards of NHS bodies
have established a safety culture. There may be a will, but there
is not a way. For 17 years the NHS has been focused upon targets
and change, mainly financial. The notion of safety has been at
the behest of clinical professionals, not lay dominated Trust
Boards. The obsession with financial targets means that clinical
and managerial staff are focused upon required results not safety.
There are only 24 hours in a day and if finance (and its consequential
targets) takes up most of this time then there is little or no
time for safety as a secondary measure.
b. systems for incident reporting, risk management
and safety improvement
Whether adequate measurement and
assessment is undertaken and acted upon. The current system is
based upon the risk matrix which is at the heart of the problem.
This is a grid that places severity and frequency on different
axes. However, whilst severity may have some general notion of
what it is, it is maimed in definition by emotive words such as
"catastrophic". Death is death, but an event listed
as catastrophic means, to a lay person, a true catastrophe. Yet
a death may be an actual predictable or expected consequence or
outcome. The record though of the incident is "catastrophic".
However, and much worse, is the portion of the matrix that uses
probability of recurrence ie "likelihood". Likelihood
is as scientifically effective as placing a wet finger in the
air to determine wind direction. The likelihood of something recurring
is future tense and speculative. If one trips and falls down the
stairs what is the likelihood of this recurring? Answer, unknown
or unlikely. But, if one's slippers are worn, or one is dizzy,
the likelihood goes up, although you may not think so yourself.
So two unscientific parameters immeasurable are used to determine
the risk values that an organisation needs to risk profile a case
scenario. So the data is wrong and so any drawn conclusions are
wrong. So, any consequent action is wrong.
The impact of the changing public-private
mix in provision. Public and private institutions have a) differing
end points to their defined needs and so b) differing pathways
to follow. If kept separate then they can co-exist. However, if
a patient goes from public to private and back to public ownership
though contract or failure of the private sector then the patient
may suffer further harm due to a lack of continuity.
c. national policy
The appropriateness of the objectives
set out in national policy statements, including Safety First
and High Quality Care for All, and what progress has been made
in meeting them. Nice words but nothing systematically to underpin
themno local nor national expert panels.
Whether past spending on patient
safety has been sufficient and cost effective, and what future
spending should be. It has been well noted that 10% of anything
that can go wrong will go wrong. It therefore follows that 10%
of budgets must be allocated to safety issues and management at
every level of the NHS from top to shop floor. Spending has not,
to date, been efficient or effective.
The appropriateness of national targets.
Inappropriate. You cannot measure something unless it is measurable
and such measurability must reflect the need to be measured ie
be appropriate to its consequence.
d. the National Patient Safety Agency and
other bodies, including:
Healthcare Commission / Care Quality Commission.
NPSA: for its cost since inception it has not evidenced the fact
that it has been directly responsible for saving one life nor
preventing a death. No annual data flow comes from NPSA despite
its assiduous collection of data.
NHS Litigation Authority. A remote organisation
aimed to reduce costs, not prevent harm.
e. education for health professionals. No Royal College
devotes the 10% required to direct patient safety issues. They
presume that if the teaching and training is correct then nothing
untoward will happen. This Nelson mentality ("I see no
ships") displays a grave error of awareness and commitment
at best and a reckless disregard for the nature of safety at worst.
There are no Collegiate Professors of Clinical Risk Management
/ Patient Safety.
3. WHAT THE
NHS SHOULD DO
Whether the measures taken to improve
patient safety are supported by adequate evidence regarding their
clinical effectiveness and cost effectiveness. Effectiveness whether
clinical or cost should reflect the principle of doing the right
thing. However, the "right thing" remains undetermined
and so efficiency (doing the thing right) dominates, even if one
is doing the wrong thing. The evidence is lacking at many levels
of safety issues as many such issues remain unidentified and so
not available for analysis.
How to determine best practice and
ensure it is spread throughout the whole NHS. This remains contentious
as "best" remains subjective and objective. Objectivity
would include many weighted strands such as outcomes as well as
morbidity, as well as environment etc. One has to declare what
best practice is and then at least the NPSA might sufficiently
distribute it. However the NPSA seems to choose easy media-friendly
targets to attain rather than real world difficult and complex
issues to tackle. A co-ordinated strategy through the many UK
universities along a strategic line for each University would
create an environment and culture of safety and accrue solid evidenced
How to ensure that learning is implemented.
As above via Universities, Royal Colleges and NPSA.
What should be measured and assessed;
and what data should be published. An interesting issue is when
incidents occurusually day time when most activity takes
place, not at night or weekend. There is much temporal data to
be extracted. Thereafter the time honed risk management tool of
Identify, Analyse and Control should be invokedagain a
standard well known throughout non-clinical industries. All data
must be published to permit external assay and analysis.
What incentives there should be to
improve patient safety. Removal of non-clinical targets and diverting
the costs to implement those targets, and political targets, into
a safety budget set for each organisation.
How patients and the public can be
involved in ensuring that services are safe. Without knowledge
of the above they cannot participate other than to give a notional
account of a perception. In this case as the saying goes "one
man's meat is another man's poison". However, skilled patients
and here I mean ex-clinicians and retired clinicians who are patients
who can straddle both camps are an untapped source of knowledge
and experience. Lay people can have a role, however it remains
personally driven, perceptive in nature and unscientific.
Dr Jeffrey C McILwain
MB BCh BAO MD FRCS
Consultant, Clinical Risk Management,
St Helens & Knowsley Teaching Hospitals NHS Trust