Select Committee on Health Written Evidence

Memorandum by Guy Hirst and Trevor Dale (PS 25)


  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 professions.

  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 healthcare—roughly one in ten patients admitted to hospital in developed countries suffers some form of medical error—systematic attempts to improve safety and the transformations in culture, attitude, leadership and working practices necessary to drive that improvement are at an early stage".

  4.  In the same document reference is made to the Department of Health's publication from 2000—An 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 revoked.

  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 optional.


    —  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.

September 2008

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