Patient safety is an important and very broad area. Many useful resources are being developed and collated on the interweb. Here we outline three unique selling points for applying Errordiary to patient safety education. These are not proven, we’re still exploring the area, so we’d welcome feedback on what is of value, where focus should be, and how things could be improved. We’ve listed some useful resources at the bottom of this page if you’d like to find out about patient safety more broadly.
The Traditional: Human Error
Undeniably human error is of paramount importance to patient safety: if we can reduce error then we can improve patient safety. However, people have different understandings and perspectives on human error that include variance in its frequency, what causes it, and what action can be taken to reduce its likelihood in the future. We want to raise awareness of the ubiquity of human error in everyday and professional contexts and we want to promote a more mature understanding of why human error happens. There is a lot of traditional research in this area. A colleague of mine spoke to a trainee nurse in China, this young girl was disinterested in the human error talk which was given, on asking why this was she said, “I’ll be fully trained soon and so this won’t be applicable”. This is only a sample of one but we are failing clinicians if they believe that training prevent error, anywhere in the world.
Errordiary can help by:
- Broaching the subject of human error in a non-threatening way. For example, when we give presentations we use everyday examples from Errordiary and people will often laugh and share knowing glances. This is a quite different reaction to when we have started to discuss patient safety incidents as people put up their defences and aren’t as open.
- We all have some abstract understanding that ‘to err is human…’ but through the 100’s of posts on Errordiary you can actually get a feeling for this and see it!
- Linking everyday errors to more serious error. Common psychological causes often underlie funny, frustrating and fatal errors. Forgetting your keys in the house is not too dissimilar to forgetting swabs in a patient after surgery. There are similar psychological causes at play and there are similar preventative actions we can take to reduce the likelihood of these things happen.
- As we have introduced abstract psychological causes we can go a little deeper and talk about the difference between slips, mistakes and violations. Many healthcare professionals do not have a background in psychology and have not been taught these concepts for understanding error. Why is this important? Because they will have a better grasp of why errors happen and appropriate remedial actions – training and just being careful isn’t always the answer!
- Once we have established that everyone makes error, that they are important for patient safety, that there are different psychological cause for these we can move on to what to do about it. We take a systems view, where we need to look at the system rather than the individuals. This includes communication, procedures, practice, training, equipment design and usability. We have a special interest in usability and so highlight this through Microwave Racing. We also have a special interest in resilience strategies, which we move on to below.
- We can then move on to the treatment of error more broadly, which includes the messy area of blame, accountability, reporting error and learning. We also move on to this in more detail below.
The New: Resilience Strategies
‘To err is human…” is a hackneyed saying. In my view it is quite negative and submissive. Someone recently wrote on Twitter that ‘failure is part of the human condition’. Someone else has called Errordiary’s #errordiary stream of human error the ‘Wall of Doom’. There admission of vulnerability and frailty is a needed step towards improvement – and it is this same acknowledgement of vulnerability and frailty that drives us to develop strategies to make us more resilient to making errors. We then have a more positive development to the hackneyed saying, “To err is human… but the proactive avoidance of error is human too!”. We want to raise awareness of resilience strategies. These behaviours are often practiced more implicitly; however, we are developing concepts and a vocabulary so people can reflect on them more explicitly. This is part of more novel research. This will hopefully mean that people can think about these behaviours more explicitly; talk about them; and adopt, adapt and share them more easily.
Errordiary can help by:
- Providing examples of everyday and professional resilience strategies that people have posted on the #rsdiary stream.
- Introducing a vocabulary for talking and thinking about resilience strategies at a more abstract level.
- Linking non-healthcare based resilience strategies with healthcare based resilience strategies, e.g. a pre-commitment check is a check that takes place before committing to some action, this is like checking all the IKEA flatpack screws, etc. are present before assembly, like checking you have all the stuff needed for a patient’s treatment before starting it, like checking you’ve got your keys before leaving the house, like checking you have all the swabs you used before sowing the patient up after surgery,
- Challenging the mind set of passivity to error to encourage people to be more proactive in developing strategies in the short and the long term to reduce error.
The Ugly: Blame and Learning
I’ve called this the ugly section as it’s a bit messy, at least in my mind, but probably out in the world too. There are elements of blame and learning felt in different parts of healthcare – here is a storify of different resources I have collated that show some of its different aspects: http://storify.com/DomFurniss/blame-and-learning-in-healthcare . We don’t have the answers here but think it is important to think and talk about these sorts of issues more. It has an impact on error, learning and resilience for patient safety.
Other Patient Safety Resources
- Human Factors in Healthcare Concordat
- RCN: http://www.rcn.org.uk/development/practice/patient_safety#
- CHFG: http://chfg.org/resource/human-factors-theory#
- The Health Foundation: http://patientsafety.health.org.uk/#
- Implementing Human Factors in Healthcare: http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Intervention-support/Human%20Factors%20How-to%20Guide%20v1.2.pdf#
- This is an extremely good paper on HF which was recently published in BMJ Q&S: http://qualitysafety.bmj.com/content/22/10/802.full.pdf+html#