Memorandum by Guy Hirst and Trevor Dale
As concerned taxpayers and potential patients
of the NHS we wish to make a submission to the Parliamentary Inquiry
about Patient Safety.
We have extensive experience of working
with teams in commercial aviation and healthcare for many years.
In aviation the inevitability of
human fallibility is accepted and training and systems are not
only put in place to minimise error but also to learn from errors
and incorporate those back into future training.
The motivation for acceptance of
these skills was mandatory training and assessment. This moved
the training from being optional and therefore avoidable to being
essential and something people had to take notice of.
We have been an integral part of
several research programs investigating human error in operating
theatres for over 6 years and have witnessed at first hand many
traits within healthcare professionals that would not be tolerated
in aviation and other high-reliability organisations.
There is an unhealthy tendency to
focus on blame rather than learning and a significant reluctance
to change particularly amongst those with enhance status in the
1. In the course of our participation in
research work over the last 6 years at several Teaching Hospitals
and DGHs we have observed the multi-disciplinary operating theatre
teams in various surgical specialties. During this work we have
observed numerous examples of less than effective team working
in the operating theatre. Such examples have the potential to
cause patient harm.
2. We have a combined experience of 70 years
in Commercial Aviation. We recently retired as senior training
captains for British Airways. Since 1990 we have both been leading
members of the small team that pioneered "human factors"
training in aviation. In the last 18 years we have learnt a great
deal about how to embed this essential training into the culture
of an industry. Despite the many overtures by those responsible
for Healthcare in the United Kingdom the understanding of the
importance of Human Factors is negligible.
3. In 2006 the Chief Medical Officer (CMO)
reported in his review Good Doctors, Safer Patients: "It
is only relatively recently that attention has been focused on
patient safety as an issue. Despite the relatively high level
of risk associated with healthcareroughly one in ten patients
admitted to hospital in developed countries suffers some form
of medical errorsystematic attempts to improve safety and
the transformations in culture, attitude, leadership and working
practices necessary to drive that improvement are at an early
4. In the same document reference is made
to the Department of Health's publication from 2000An
Organisation with a Memory - which highlighted failure to
learn systematically from things that go wrong, in marked contrast
to other high-risk industries. The report demonstrated the importance
of improved and unified mechanisms for detecting safety problems,
the importance of a more open culture and the value of a systems
approach to preventing, analysing and learning from adverse events.
5. On July 14th 2008 the CMO for England
published his report on the State of Public Health for 2007. In
the chapter entitled While You Were Sleeping: Making Surgery
Safer he refers to the groundbreaking work being developed
at The Royal College Of Surgeons of England. "The Royal
College of Surgeons of England currently offers a course to address
patient safety issues. This involves surgeons and representatives
from other high-risk industries. It targets issues of leadership,
effective team-working and risk reduction to improve patient safety".
6. We are two of the representatives mentioned
by the CMO. As mentioned earlier we refer to the skills alluded
to by the CMO, Human Factors skills. Human Factors are those skills,
not directly technical, that describe how members of a team function
effectively and safely. Human error cannot be eliminated; it is
an essential facet of the human condition. However efforts can
be made to mitigate, catch and minimise errors and threats by
attempting to provide people with appropriate skills to cope with
the risks and demands of their work. These skills are the cognitive
and social skills that complement workers' technical skills. Whilst
many healthcare professionals intuitively demonstrate these skills
many others do not. In aviation and other safety critical industries
it has long been recognized that these skills are trainable. Over
the last decade, in aviation, human factors training has become
mandatory. The skills are assessable and mandated by the regulator.
Any pilot unable to demonstrate the skills will have his license
7. In our recent research we have delivered
human factors training courses to the surgical teams. The content
and style of the courses are based on evidence from other safety
related industries but tailored to the healthcare professionals'
needs. Subjects covered include: Leadership, Team-working, Communication,
Cognitive Awareness and Decision Making skills.
8. We have established a collection of case
studies from our own observations with distinct and discrete details
of specific behaviour of hospital professionals. Some of these
are highly effective and contribute to patient safety, some do
not. These include distraction of surgical team during a complex
operation with loud rock music in theatre by a senior consultant
surgeon; rudely ignoring safety-related inputs from junior team
members; absence from theatre of critical team members without
announcing the fact; refusal to discuss surgical accidents with
other team members and many more.
9. Research indicates that one of the most
effective methods of making teams safer and more efficient is
by having a briefing prior to embarking on a task, particularly
a complex and safety-critical one. The briefing is an opportunity
to plan for the expected and to prepare for the unexpected. Research
also indicates that a post task debriefing is essential to allow
team members to learn from the event. Both briefing and debriefing
are skills that need to be understood and practiced.
10. Changing culture is a challenge in any
industry and in an organisation the size of the NHS that challenge
is even greater. It is imperative to have a well-considered programme
to train all Healthcare professionals so they understand the importance
of the human condition and how that condition can affect patient
safety. Once that training is in place the next step is to regulate
the organisation so that demonstration of these skills is no longer
We believe that training of non-technical
(teamworking) skills should be introduced immediately at all stages
of medical education and across all disciplines.
There are many NHS staff who recognise
the problems and are capable of suggesting solutions. They should
be encouraged to develop these solutions which would fit the culture
prevalent within their own Trust.
Independent investigation of unsafe
occurrences must be mandated to avoid protectionism.