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Risky Business

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It is about 18 months since, Professor Don Berwick published A promise to learn – a commitment to act, a report on the safety of patients in England.

The Berwick report followed tragic events at Mid Staffordshire NHS Foundation Trust, which triggered a need to re-examine what the NHS does and determine how it can improve further. Don Berwick’s report did just that, and found that “The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care”.

We know that across the world, about one in ten patients experience unintentional harm whilst in hospital. It's a shocking statistic, and whilst many of these patients experience only very minor harm, some are significantly affected and a small number tragically die.

At our Board meeting this week I was very disappointed to report that the Trust has had a never event in January and again in February. Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been put in place. Both events reported at the hospital related to wrong site surgery and are being investigated through the Serious Untoward Incident process and have been shared with the patients and their families.

Healthcare is a complicated and risky business. But often when things go wrong in hospitals across the world it's not because the patient was particularly sick, or the operation was particularly complicated, it's because the systems and processes weren't good enough and allowed a basic human error to occur.

This is why I'm an advocate of the World Health Organisation (WHO) safety check list. It's impressive that such a simple process - the team calmly double-checking everything together and planning for the procedure they're about to do - has been proven to save lives across the world. It demonstrates that making sure the basics are in place allows the team to then get on with the difficult and sometimes very risky work in a safer environment.

We all have an important part to play, and it’s not just surgical procedures. It is every part of our service. How well are we performing our key safety processes? How safe are we today? How safe are we going to be tomorrow? How well are we responding to past events? The checklist supports internal transparency and accountability for safety. We need to regularly ask ourselves and each other, the following questions:

  • How do you know you had no problems in the past 24 hours?
  • What immediate, remedial actions did you take?
  • Is this happening in other places? Could this happen in other places?
  • What other areas does this issue impact?
  • How are you preparing you, and your team, for that high-risk task?
  • What error prevention behaviours should be used?

Patient safety is not by its nature absolute. We can always be safer, we can always improve and we will always have to strive to reduce further the risks for our patients. But patient safety is also about being bold and taking great leaps forward. A journey of continuous improvement coupled with ambitious goals will transform the NHS into the safest health care system in the world.

About the Author

Tony image

Chief Executive of Countess of Chester NHS Foundation Trust.

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