Patient Safety - Health Committee Contents

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."[137] 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[138] 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.[139]

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.[140] This is also the basis for the "Productive Ward" programme,[141] 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 we do".

125. In the Intensive Treatment Unit, we heard how goals had been set of a 50% reduction in central venous line infections[142] and 95% compliance with the Central Line Bundle—a 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.[143]

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,[144] 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.[145]

Teamwork and other non-technical skills

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 skills—such 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".)[146] Some examples of such skills are given in Box 11.Box 11: Examples of non-technical skills
  • teamwork / team coordination;
  • communication;
  • leadership;
  • decision making;
  • conflict resolution;
  • assertiveness;
  • 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.[147]

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.[148]

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.[149]

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.[150]

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 skills—but strong cultural resistance to the new way of working meant change was not sustained.[151]

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" among clinicians:

    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.[152]

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.[153]

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 theatres.[154]

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.[155]

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 Out"); and
  • before the patient leaves the operating theatre ("Sign Out").

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.[156]

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.[157]

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.[158]

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.[159] 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: […] [U]nfortunately, 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 anyway.

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.[160]

Staffing levels


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.[161]

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.[162]

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.[163]

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.[164]

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.


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 […][165]

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.[166] 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".[167] 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.[168]


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 fully below.

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 into further.

137   Committee of Public Accounts, A safer place for patients, p 6 Back

138   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

139   Q 691 Back

140   "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

141   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

142   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

143   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

144   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

145   Ev 123. See also Ev 93. Back

146   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" ( Back

147   Q 666 Back

148   Ev 121 Back

149   Ev 95 [Guy Hirst and Trevor Dale] Back

150   Ev 94, 95 Back

151   Ev 122 Back

152   Ev 91 Back

153   Q 165 ff. Back

154   Ev 92 Back

155   Qq 78, 684 Back

156 Back

157   Q 354 Back

158   Ev 33 Back

159   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

160   Q 684 Back

161   Ev 205 Back

162   Healthcare Commission, Investigation into outbreaks of Clostridium difficile at Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust, July 2006, p 9 Back

163   Healthcare Commission, Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust, October 2007, p 108 Back

164   Healthcare Commission, Investigation into Mid Staffordshire NHS Foundation Trust, March 2009, pp 43 and 58 Back

165   Q 373 Back

166   Q 894 Back

167   Q 1108 Back

168   Ibid. Back

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