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03rd January 2012

To Err is Human

I have a strong memory of an incident from my childhood. My Mother was changing a light bulb in a table lamp and in anticipation of leaving me with the stricken light-fitting for a moment, she said “Don`t stick your finger in that hole, I`m just going to fetch a new bulb”. Well, you might already know what I did the moment her back was turned. Out of childish curiosity, I did just the wrong thing, and the resulting shock sent me flying across the room with a yell! My Mother`s reaction, after making sure I was still alive, was to say “You won`t do that again!”

She was right.  Through the rest of my childhood and my adult life, so far, I have never repeated the action of putting my finger in an empty light socket.  This was a really useful learning experience for me with regard to the dangers of electricity, and my Mother learned not to leave me in potentially dangerous situations.  All incidents, however severe or trivial the consequences, are fantastic and valid learning tools.

One would think, and hope, that healthcare organisations would treat them similarly.  However, despite  the NHS being christened a `an organisation with a memory` (alluding to learning from previous problems)in a government white paper in 2000, the number of patients affected by adverse incidents has stayed at about 10% through the years.  We are just not that good at using these golden opportunities to look at what we do and reduce risk to our patients.

In 1943 the American Airforce invented something so simple, but so effective, called Significant Event Analysis (SEA).  They used this to investigate reasons for failures in bombing missions over Europe, and improved their effectiveness considerably.   This system has been used by various organisations since the Second World War and adopted by healthcare systems across the world as a standard for using failure as a way of finding success.  If it is so good, why are we not doing this every day in the UK?  The answer lies in two misconceptions.  Firstly, we are put off by anything involving the word `analysis` as being too complicated or specialist, when in fact I`m about to explain in just a few words how to do it.  Secondly, it involves a little investment in time.  When we are so busy, it is difficult to allow another activity to get in the way, but this will be paid back a thousand-fold in lost time, and heartache, through averting repeat problems.  The time involved might be as little as ten or fifteen minutes built into a regular practice meeting.

First of all, what is a Significant Event?  The formal definition is “….any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice.”  This can be clinical or financial, it can be in the surgery or in reception, it can be something affecting just staff or just patients.  Pretty certainly, a significant event happens at least once a day in general practice.  We are working on a flat playing field here, so it can be recognised by anyone in the team, from top to bottom.  This also works better if carried out in a non-judgemental way, we are here to learn, not blame!  More importantly, it can be positive or negative, as we need to recognise events reflecting good practice so that the whole team can learn and be encouraged.

For convenience, there are really only three types of `event`: Good Practice, Near Miss and Adverse Event.  We don`t celebrate Good Practice enough, so here is a chance to recognise good work by people.  For example, not forgetting to give out Patient Feedback requests, even on busy days.  They quite often produce amazing Testimonials which can be used on your website.  When a good comment comes in, recognise the staff who take the trouble to ask for feedback!

A Near Miss incident is one of those `Phew` moments.  Once in a while, finding the wrong notes on the computer screen throws up the potential for extremely embarrassing, and costly, problems.  How many `Mrs A Smiths` does it take to encourage the automatic practice of checking the date-of-birth in the surgery too?

An Adverse Event involves a real harm rather than a potential problem.  Having to send a patient away because the appointment is wrong has a financial implication, giving Amoxil to someone who is sensitive to Penicillin has a more serious effect, but both are valid for team based discussion.

Now, let`s make it simple.  SEA is based on just four stages of asking yourselves, what happened, why did it happen, what have you learned and what will you change.  So let us look at an example, but I`ll try to get away from the boring practice based stuff.  The other morning I got into work with a sore knee and an embarrassing tear in my trousers.  This was not a good start to the day, but we might use it for a learning exercise because I do not want to go through that again.  The first stage is to establish what happened.  Very simply, at 8.46am I fell over on my drive between the front door and the car.  That is establishing a time, a place and a context.

Why did it happen?  Some people see this analysis stage as the complicated part, but one is allowed to make it simple and the simplest risk analysis is to ask the `5 whys`.  So, why did I fall?  I tripped over my untied shoelace.  Why was it undone?  I forgot to tie them earlier.  Why did I forget?  I forgot because I was in a rush.  Why was I in a rush?  Because I overslept.  Why did I oversleep?  Because I do not always set the alarm.  So, now we have a root cause, and it doesn`t always take all five `whys` to get there.

What have I learned?  Quite simply, I`ve learned that not setting the alarm can have consequences of which I was unaware before.  Not only can I oversleep and be rushed and stressed, I can also put myself in danger.  Finally, what will I change?  The final answer is that I now have a protocol and procedure which is concerned with always setting the alarm before a weekday.  Risk averted.

There are added bonuses to incorporating this sort of procedure into everyday life at work.  Keeping records of these discussions is proof of meeting standards required now through CQC and other professional contracts.  Encouraging a culture of safety awareness also has a positive effect on staff moral and enthusiasm, because they feel that their views are heard too.  Making yourself do this is about total honesty and openness within the practice, and although it can feel harsh at the time the benefits are profound in opening up new communication channels throughout the practice team.

Before you finally put this article down, go back to the beginning of the SEA process and start it with any incident that has occurred within the practice in the last year, or even the hypothetical case of the Amoxicillin prescription.  If this can prevent receiving a letter from solicitors acting on behalf of a deceased patient it will be worth it.                                          ..... and finally check your shoelaces!

Topics: General

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