6 Patient safety at the front line|
119. In this chapter we consider some of the major
factors in determining whether or not safety becomes deeply rooted
in frontline services. In many cases, the measures needed to resolve
specific safety issues have been identified and proven by research
to work. However, all too often these measures are not implemented
at the front line in the NHS as the PAC noted in 2006: "Patient
safety alerts and other solutions are not always complied with
though trusts self-certify that they have implemented them."
Professor Sir Ian Kennedy, then Chairman of the HCC, told us:
If I could draw a distinction between what I
would call structural responses, which have been quite significant,
the creation of the NPSA, the National Patient Safety Forum
and other such exercises, Darzi's review, and so on, contrast
that with cultural changes and behavioural changes and I think
they lag behind in translating ideas into reality.
120. There are, however, NHS organisations which
have made significant and lasting improvements in safety, as we
discuss below. We also look at proven solutions in the field of
non-technical skills that have yet to be widely adopted in the
NHS. We also consider how the safety of services can be undermined
by a sheer lack of adequate staff numbers.
Empowerment and improvement
121. At Luton and Dunstable Hospital, we were most
impressed by pioneering work that has demonstrated how frontline
staff can be empowered to redesign services, making them both
more efficient and safer. This hospital has made "clinical
leadership" and "clinical engagement" into a reality,
rather than just slogans. We were impressed by the recognition
that improvement happens when staff see what needs to be done
and seek to do it. The major barrier to improvement is the sense
that change is being imposed, probably to advance the careers
of those who seek to impose it.
122. We heard about the "transformational approach"
at Luton and Dunstable Hospital, whereby ambitious goals have
been set for the improvement of services, which are being achieved,
not by diktat, but by motivating staff to take the lead in a process
of "continuous improvement". Data on deficiencies in
services (derived from a case note review) were presented to staff,
and volunteers came forward to participate in a patient safety
improvement project. The hospital then became the exemplar site
in England for the Health Foundation's SPI programme.
123. SPI is a structured process for identifying
and addressing patient safety and quality problems, drawing on
the industrial management strategy of "lean" thinking.
This is also the basis for the "Productive Ward" programme,
which was piloted at Luton and Dunstable Hospital, as we heard
from frontline staff who had found it very worthwhile. This is
being used in New Zealand, at Middlemore Hospital in Auckland,
where it is known as the Whai Manaaki ("More time,
Better care") programme. We found this too very impressive.
At Middlemore we spoke to nurses who had created significantly
more time which could be devoted to better care for patients by
thinking how they could reorganise their ward more sensibly. Much
time was saved just by moving equipment to better locations.
124. At Luton and Dunstable Hospital, several "workstreams"
were set in train, involving frontline staff in achieving a series
of specific, measurable goals. An overall goal was set of reducing
adverse events (as measured using case note review) by 50% and
creating "a culture that puts patients at the centre of everything
125. In the Intensive Treatment Unit, we heard how
goals had been set of a 50% reduction in central venous line infections
and 95% compliance with the Central Line Bundlea group
of evidence-based interventions that, when implemented together,
result in better outcomes than if they were implemented individually.
This has resulted in a significant improvement, such that central
line infections are now very rare and seen as exceptional occurrences,
rather than a normal risk associated with this procedure, as senior
clinicians had tended to see them at the beginning of the process.
126. Research into the application of "lean"
thinking to the improvement of patient safety is currently being
undertaken by the Quality, Reliability, Safety and Teamwork Unit
at Oxford University. The Unit is looking at ways of bring about
lasting improvements in safety on surgical wards by reducing recognised
preventable complications, such as deep venous thrombosis,
which can be addressed by the thorough application of well-established
standard prophylactic (preventative) measures. Although the research
has yet to be completed, early results apparently show sustained
improvement in deep vein thrombosis prophylaxis.
Teamwork and other non-technical
127. Safety science also encompasses the realm of
"non-technical skills", which have been shown to have
a significant impact on patient safety. Non-technical skills are
the cognitive and social skills (complementing technical skillssuch
as clinical skills in healthcare) that allow people working in
safety-critical industries to function effectively and safely.
(They are also often referred to as "Human Factors".)
Some examples of such skills are given in Box 11.Box
11: Examples of non-technical skills
- teamwork / team coordination;
- decision making;
- conflict resolution;
- coping with stress and fatigue;
- workload management;
- prioritisation of tasks;
- situation awareness.
128. Many people will use non-technical skills intuitively alongside
their technical skills. However, others (who may be highly competent
in technical terms) will need to be taught non-technical skills.
They may assume that advanced technical skills are sufficient
for safe practice and not see the need to learn another set of
skills for which they have little or no natural aptitude.
129. The importance of non-technical skills has long
been recognised in other safety-critical industries, such as civil
aviation. Healthcare, however, is seen as lagging behind in this
regard, despite the fact that analysis of adverse events and psychological
research both show that proficiency in non-technical skills contributes
significantly to enhanced technical performance, reduced error
and improved safety.
130. Non-technical skills have become increasingly
important in medicine in recent decades as healthcare has become
much more complex and dependent upon invasive technology with
greater scope for things to go wrong and cause harm. The growing
complexity of medicine has been accompanied by increasing specialisation
among clinicians and greater devolution of knowledge, skills and
responsibilities within clinical teams. These developments make
effective teamwork in healthcare all the more crucial to safety
and effectiveness. Rigid and narrow professional hierarchies,
once the norm in clinical practice, need to give way to new modes
of working, characterised by a "flat hierarchy". Safe
and effective healthcare depends increasingly on close interdisciplinary
teamwork between a range of clinicians and other healthcare workers.
131. The evidence we received from two trainers in
non-technical skills illustrates how far the NHS has yet to go
in this respect:
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.
132. The trainers, Trevor Dale and Guy Hirst, are
both retired airline Captains who have been involved since 1990
in non-technical skills training, using the civil-aviation "crew
resource management" model. They state in their evidence
that "Despite the many overtures by those responsible for
Healthcare in the United Kingdom the understanding of the importance
of Human Factors is negligible". They point out that, while
Human Factors training has become mandatory in the aviation industry,
this is not the case in healthcare. They particularly recommend
the use of "briefing and debriefing" of teams engaged
in safety-critical tasks.
133. As previously mentioned, the Quality, Reliability,
Safety and Teamwork Unit at Oxford University is currently conducting
research on the effectiveness of interventions to improve patient
safety. As part of this research, the Unit studied a surgical
team before and after its members had participated in a training
programme based on civil-aviation principles (Crew Resource Management).
This showed an improvement in teamwork and a reduction in technical
errors by addressing deficiencies in non-technical skillsbut
strong cultural resistance to the new way of working meant change
was not sustained.
134. The memorandum submitted by the Clinical Human
Factors Group cites further evidence of the connection between
teamwork skills and error rates:
Studies in paediatric cardiac surgery at Great
Ormond Street [Hospital for Children] showed a clear correlation
between the quality of teamwork and the frequency of technical
and procedural errors in operations [
] and this has been
confirmed by the [Quality, Reliability, Safety and Teamwork Unit]
in Oxford [
] Not surprisingly, operations where there are
a large number of minor technical errors are more likely to result
in a serious major problem.
135. The Group refers to the case of Elaine Bromiley,
who died while receiving treatment in the private sector. Her
death was attributable to "Failings in leadership, decision-making,
prioritisation, situational awareness, communication and teamwork"
These same "human factors" are the
direct cause of 75% of aviation accidents. Many safety critical
industries refer to these [non-technical skills] yet no member
of this team, and virtually no clinician in the UK receives any
training in these vital skills. There is a clear correlation between
[Human Factors] skills and the frequency of error in operations.
Minor errors are frequently tolerated but they are significant
as they accumulate to cause major hazards. Minor errors must be
recognized and reduced by [Human Factors] training.
136. Mrs Bromiley's widower, Martin Bromiley, a commercial
pilot who chairs the Group, told us about his wife's case and
explained how it illustrated the difference between healthcare
and the airline industry. Mrs Bromiley died of a recognised anaesthetic
emergency ("can't intubate, can't ventilate"), for which
established guidelines exist. The team were technically competent
to respond, but lacked the situation awareness, and the personal
and team organization, needed to deploy their undoubted technical
skills to do what was required.
137. Another issue raised by the Group was the importance
for patient safety of routine checking in the context of surgery:
Routine surgical and anaesthetic checks are not
carried out, equipment problems are frequent and adherence to
basic procedures is variable [
] In the absence of pre-operative
checks, crucial equipment and prostheses are missing in many operating
We heard that checklists have long been used in civil
aviation, and are an important part of the Human Factors approach
to safety that has become so well-embedded in that industry.
138. In light of the evidence of widespread failure
to use checking processes in surgery, the World Health Organization
(WHO) has developed a Surgical Safety checklist, for use at three
points during an operation:
- before the patient is offered
anaesthesia ("Sign In");
- before any skin incision is made ("Time
- before the patient leaves the operating theatre
At each of these points, a checklist coordinator
must be permitted to confirm that the team has completed its tasks
before it proceeds any further. The primary aim of using the list
is to target the three biggest cause of mortality in surgery:
- preventable infections;
- preventable complications from bleeding; and
- lack of safety in anesthesia.
139. The checklist was launched in June 2008 as part
of the WHO World Alliance for Patient Safety "Safe Surgery
Saves Lives" initiative. It was trialled in eight pilot sites
across the world (one of which was St Mary's Hospital, London)
during 2007-8; and the results of the trials were published in
the New England Journal of Medicine in January 2009. The
NPSA subsequently issued a Patient Safety Alert, requiring "healthcare
organisations in England and Wales to implement the WHO Surgical
Safety Checklist (adapted for England and Wales) for every patient
undergoing a surgical procedure" by February 2010.
140. We were told by John Black, President of the
Royal College of Surgeons of England, that:
Lots and lots of hospitals have had safety check
lists for a long, long time and when the original WHO 15-point
one came up with the College council, most people said, "But
we have got far more rigorous ones in use in our hospital at the
moment." For example, in my own hospital in Worcester you
would not have got through the theatre door on that check list;
it is far more rigorous. Clearly, remember, this is designed for
international use, but it is a good thing because you cannot be
too careful on the real basics. Of course it will be accepted
by surgeons, and it does not take much time to do, and we have
given it our full support.
141. However, we heard from National Concern for
Healthcare Infections that:
Unfortunately some surgical staff oppose the
use of such checklist as denigrating their professional expertise
and have drawn comparison with motor mechanic worksheets.
142. We were also informed by Dr Kreckler about adherence
to the NPSA's 2005 Patient Safety Alert on Correct Site Surgery,
which mandated a form of checklist.
He stressed the importance of empowering and involving staff in
ensuring uptake of patient safety solutions:
Q 503 Sandra Gidley: In your experience
are [checklists] always used?
Dr Kreckler: [
] The short answer to that
is no. The reason for that really depends on the way in which
this initiative is implemented locally. It depends on those who
require to use it to understand the purpose of it, if they are
adequately trained and educated and the fact that we have evidence
behind this [
] They were required by the NPSA towards the
end of 2005. This requires that you sign a box when the patient
is first consented, when they leave the ward, when they arrive
in the anaesthetic room, and just before the operation starts,
to confirm that you have the right patient, the right operation,
and that it is the right side. I certainly know of situations
where I have seen the scrub nurse bring a form down to the coffee
room, to be signed by a surgeon in the coffee room rather than
the surgeon going to check the patient in the room. These are
not bad surgeons, these are not people who are flippantly ignoring
safety protocols, they simply do not appreciate the purpose of
the form because they have not been adequately trained. [
Q 505 [
] Dr Kreckler: [
it is the way these things are implemented [
] It is not
going to happen with a big stick and a diktat because you automatically
get resistance to that. Certainly, the way the Saves Lives surgery
was implemented in my experience, was that it was done one day:
"This is what you're going to do from tomorrow" and
everyone was, "Oh, another box-ticking exercise." There
was no explanation, nothing to back it up. If it is done properly,
I think everyone will do it and will embrace it. I think that,
with time, it will become part of the culture and will be done
We heard a similar view from Captain Hirst:
It is no good saying "use a checklist",
people have to understand it has to be sympathetically introduced
with the right sort of training to know why you are using it,
how you are using it. I do not think just saying, "Use that,
everything will be okay", will work. I am concerned that
in some hospitals we go to they are bringing in sensible programmes
to introduce it and in others it is almost by email, "From
next week you will use a checklist" and I do not think that
will work. That is my concern, that a "from on high"
downwards diktat is not the way to really get serious change.
SHORTAGES OF STAFF
143. Despite the huge increase in the number of staff
in the NHS, there is evidence that inadequate staffing levels
in some cases have been a significant factor in undermining the
safety of care. The HCC stated that:
Having the right number of competent staff is
key to safety. A number of commission reviews have looked at this
area. For example our recent review of maternity services found
that levels of staffing were well below the average, indicating
that they may have been inadequate [
] Our 2007 review of
children's hospital services found that in a small number of hospitals
(12%), there was insufficient cover during the day to ensure that
effective paediatric life support was available in serious emergencies.
At night, this figure rose to 18%. Our review of day surgery found
it was common that a child trained nurse was not always available
when children were being treated.
144. In investigating the major lapses in safety
at Stoke Mandeville Hospital, Maidstone and Tunbridge Wells Trust,
and Mid-Staffordshire Trust, the HCC found that understaffing
had been a key factor (see Box 12).Box
12: Illustrative extracts from HCC investigation findings on understaffing
|Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust
Low levels of staffing made it particularly difficult for nurses to find time to practise good hand hygiene, to answer call bells and empty commodes promptly, to clean mattresses thoroughly, to use new or properly cleaned equipment for each patient, to wake patients to give them their antibiotics, to complete fluid balance charts and to supervise confused patients who wandered in and out of isolation areas.
Maidstone and Tunbridge Wells NHS Trust
The medical and surgical wards at the trust had a history over at least three years of low staffing levels and a relatively low proportion of qualified nurses [
] Staff across several professions commented that shortages of nurses contributed to the spread of infection because they were too rushed to communicate with their colleagues, wash their hands, wear aprons and gloves consistently, empty and clean commodes and clean mattresses and equipment properly.
Mid-Staffordshire NHS Foundation Trust
Receptionists were responsible for assessing any patients who did not arrive by ambulance. This was as a consequence of having too few trained nurses to maintain consistent triage [
] [Staff] described the EAU [Emergency Admissions Unit] as "dreadfully understaffed" [
] Patients and relatives of patients who had been treated on the EAU had a general impression that the unit was short-staffed [
] [P]atients reported not getting basic care, such as washing and being escorted to the toilet. There was a lack of support noted for patients needing help to eat [
] One patient told us that EAU was generally chaotic, filthy and there was a lack of basic hygiene control; for example he did not see any hand washing.
145. Other cases where staffing levels have been an issue are
referred to in the Commission's document Learning from Investigations
(2008), to which we were referred by Professor Kennedy.
EUROPEAN WORKING TIME DIRECTIVE
146. An additional issue regarding staffing levels is posed by
the likely impact on safety of new European Working Time Directive
(EWTD) rules, due to be introduced from 1 August 2009, under
which junior doctors will not be allowed to average more than
48 hours per week on call except in certain limited circumstances.
We heard from the Royal College of Surgeons of England that this
will lead to inadequate cover at evenings and weekends, and multiple
handovers of patients, which will be detrimental to patient safety.
In addition, it will take longer for a surgeon to obtain the experience
needed to become fully trained. Mr Black, President of the Royal
College, told us this was:
the biggest threat to patient safety and, not only that, to
delivery of service for a long, long time [
] [W]e anticipate
significant service failures [
] Next summer, if this is
implemented, there are many hospitals and units that will not
be able to provide a service and will be closing [
The Royal College argued that the Government should opt out of
the EWTD to allow junior doctors to work a 65-hour week on-call
with adequate rest breaks.
147. Lord Darzi responded that the EWTD was in fact a means of
protecting patients from being harmed by overtired surgeons.
The Minister of State for Health Services, Ben Bradshaw MP, told
us that "tired doctors are not only dangerous for patients
but they are dangerous for doctors". He was "confident
that the health service would be in a position to implement this.
It will require the re-organisation of services in some hospitals".
Professor Keogh, the NHS Medical Director, did not agree that
there would be "a disaster" on 1 August, but he did
think "it is going to be very challenging". He reported
that a working group on derogation from the Directive was considering
220 applications from services to derogate on grounds of "physical
reorganisation of plant or services" or "difficulties
of recruitment into some specific specialities". Regarding
the impact on training, the Postgraduate Medical Education and
Training Board was being commissioned to look at this.
148. Too often known patient-safety solutions fail to be adopted
in the NHS even when they are disseminated by means such as Patient
Safety Alerts. They are handed down from on high as diktats (if
they are passed on at all) without frontline clinicians being
convinced of their effectiveness. Moreover, a culture persists
in which various types of harm to patients are seen as inevitable
when in fact they are avoidable if the right steps are taken.
149. Some organisations, however, have shown that
it is possible for improvements to be fully integrated in frontline
services by engaging and involving clinicians, and other healthcare
workers. The focus needs to be on tangible improvements to health,
drawing on staff's own initiative.
150. "Lean" thinking, using the initiative
of frontline staff to increase efficiency and use time more effectively,
is beginning to be introduced into the NHS through schemes such
as the Productive Ward programme and the Safer Patients Initiative.
This approach has much to commend it. If less efficient ways of
working can be eliminated then more can be achieved and standards
of care raised.
151. Lack of non-technical skills can have lethal
consequences for patients. However, the NHS lags unacceptably
behind other safety-critical industries, such as aviation, in
this respect. Human Factors training must be fully integrated
into undergraduate and postgraduate education, as we discuss more
152. Routines and, in particular, checklists are
an important aspect of safety in healthcare as in other activities.
We welcome the implementation of the World Health Organization
Safe Surgery checklist. While similar measures are already used
in NHS hospitals, we are concerned that such checklists are not
always followed because clinicians regard them as diktats and
do not always see the point of them. We recommend that clinicians
who persistently disregard these checklists should undergo retraining.
153. Despite the massive increase in the numbers
of NHS staff in recent years, inadequate staffing levels have
been major factors in undermining patient safety in a number of
notorious cases. It is clearly unacceptable for care to be compromised
in this way. NHS organisations must ensure services have sufficient
staff with the right clinical and other skills.
154. Regarding the new European Working Time Directive
rules, we are not convinced by the more alarmist claims being
made that these will seriously jeopardise patient safety when
they are introduced on 1 August 2009. But we do seek assurance
from the DH that everything possible is being done to ensure that
safety is not compromised. Professor Sir Bruce Keogh, the NHS
Medical Director, did agree that 1 August "is going to be
very challenging" and he told the Committee that derogation
for some services and the impact on training were being looked
137 Committee of Public Accounts, A safer place
for patients, p 6 Back
Safety First (2006) recommended the establishment of a
National Patient Safety Forum to "harness the skills and
expertise of a number of organisations, agencies and stakeholders
which are making a significant contribution to patient safety"
and run a "national patient safety campaign-focused initiative"
(pp 24 and 25). The Forum began meeting in February 2007. The
Patient Safety First Campaign for England began in September 2008,
but the Forum does not appear to be running this. Back
Q 691 Back
"Lean" thinking was developed by the Toyota motor company.
It entails empowering and motivating shop-floor staff to streamline
and improve processes, reduce waste, improve quality, and deliver
products and services in a more timely way. Back
The "Productive Ward" was developed by the NHS Institute
for Innovation and Improvement. It entails involving shop-floor
staff in designing and implementing more efficient ways of working,
bypassing conventional management chains of command. Back
A central venous line (or catheter) is a tube placed into a large
vein in the neck, chest or groin to provide long-term access to
the vein, for treatment and diagnostic purposes. Poor management
of a central line can lead to a bacteraemia (bloodstream infection),
prolonging length of hospital stay and, in some cases, causing
the death of the patient. Back
A national initiative around this issue, starting in April 2009,
was announced by Lord Darzi in his final report for the NHS Next
Stage Review (Department of Health, High Quality Care For
All: NHS Next Stage Review Final Report, Cm 7432, June 2008,
para 55, p 45). This initiative (now called "Matching Michigan")
involves emulating a successful project in Michigan, in the USA;
the NPSA has been working with Johns Hopkins Hospital on it (Ev
152 [National Patient Safety Agency]). Back
Deep venous thrombosis is the formation of a blood clot in a deep
vein, which can be fatal; admission to hospital for some medical
illnesses as well as for surgery is a risk factor for this condition.
Risk assessment for all patients admitted to hospital would lead
to appropriate preventative measures being taken for every patient. Back
Ev 123. See also Ev 93. Back
Strictly speaking, the term "Human Factors" has a much
broader definition than non-technical skills. The Health and Safety
Executive defines Human Factors as "environmental, organisational
and job factors, and human and individual characteristics which
influence behaviour at work in a way which can affect health and
safety" (www.hse.gov.uk/humanfactors). Back
Q 666 Back
Ev 121 Back
Ev 95 [Guy Hirst and Trevor Dale] Back
Ev 94, 95 Back
Ev 122 Back
Ev 91 Back
Q 165 ff. Back
Ev 92 Back
Qq 78, 684 Back
Q 354 Back
Ev 33 Back
The Correct Site Surgery Alert (March 2005) mandates measures
to ensure that operations are carried out on the correct site
in the patient's body. It was superseded in February 2009 by the
Alert mandating use of the WHO checklist. Back
Q 684 Back
Ev 205 Back
Healthcare Commission, Investigation into outbreaks of Clostridium
difficile at Stoke Mandeville Hospital, Buckinghamshire Hospitals
NHS Trust, July 2006, p 9 Back
Healthcare Commission, Investigation into outbreaks of Clostridium
difficile at Maidstone and Tunbridge Wells NHS Trust, October
2007, p 108 Back
Healthcare Commission, Investigation into Mid Staffordshire
NHS Foundation Trust, March 2009, pp 43 and 58 Back
Q 373 Back
Q 894 Back
Q 1108 Back