The knowledge that clinical systems can cause harm is not new, but the size of this problem has not previously been established systematically. This Health Foundation report therefore provides groundbreaking evidence of the extent to which important clinical systems and processes fail and the potential these failings have to harm patients.
“Rather than being the instigators of an accident, operators tend to be inheritors of system defects …. their part is usually that of adding the final garnish to a lethal brew using ingredients that have already been long in the cooking” (James Reason, 1990).
A significant proportion of the liability failures identified in the research were associated with risks to patient safety. For example, the report identified that 15% of outpatients’ appointments were affected by missing clinical information. In 20% of these cases the doctors involved judged the patients to be exposed to risk. A fully reliable systems function as intended under expected conditions. The clinical systems for which reliability could be assessed in the study had an average failure rate of 13-19%. That would not compare favourably to any 21st century process, let alone the airline industry! There was significant variation between organisations in reliability ranging from 63% of equipment available in one organisation, to 96% for availability of clinical information in another Acute Trust in the study.
Across the range of systems and organisations studied unreliability was usually a result of the same factors. These included: a lack of feedback mechanisms for both individuals and systems; poor communication; and widespread acceptance on the part of clinical staff that systems are going to be unreliable BOLDand that this is not their responsibilityBOLD.
The variation between and within organisations suggests that it is possible to create systems that have higher reliability – that requires clinical leadership. The importance of leadership comes out loud and clear from the review of the National Patient Safety Agency report on the patient safety first campaign which used social marketing principles to mobilise the NHS staff resulting in an increase from 18% to 61% of Acute Trusts having patient safety and quality as their first agenda item. The campaign promoted 5 interventions: leadership; deterioration; critical care; perioperative care; and high risk medicine. All of these would be useful in making a step change to the recognition and outcomes in acute kidney injury.
I would add a sixth vein – to move from a blame culture to a culture of learning from failure. A knowledge system like the NHS will only provide the care we want if its components are learning organisations. The ingrained attitude that all failures are bad often means organisations don’t learn from them. All staff need to feel safe admitting to and reporting failures. Creating that environment takes strong leadership.