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Risky business: adverse events in healthcare

Every person who steps over the threshold of the hospital or doctor’s surgery has to accept that they are potentially at risk of medical negligence. The surgeon’s instruments are sharp, medicines are potentially toxic and the human body is immensely complex, each individual differing in their basic anatomy and reaction to interventions.

It is when harm is seen as avoidable that the acceptance of this risk becomes unreasonable. The public have witnessed a litany of reports and investigations into cases where avoidable harm has been caused to patients, only for normal service to be resumed until the next time.

This week has seen the launch of two major initiatives which may (or may not) help to change the entire culture of the NHS approach to errors (traditionally seen as one of blame and fear) to one of active and open learning from adverse events.

Firstly the NHS Litigation Authority has a new name and a new mission. NHS Resolution will be a key part of the Department of Health’s stated ambition to improve safety and learn from avoidable deaths. The health secretary Jeremy Hunt claims that the rebranded body “will radically change its focus from simply defending NHS litigation claims to the early settlement of cases, learning from what goes wrong and the prevention of errors”.

The second development that may herald a sea change in the approach taken to clinical incidents and learning is the official launch of the Healthcare Safety Investigation Branch (HSIB).

The establishment of the HSIB was a key manifesto aim of the Clinical Human Factors Group (CHFG), set up by airline pilot Martin Bromiley after the death of his wife in the anaesthetic room whilst undergoing routine surgery. Oxford academics Carl Macrae and Charles Vincent have been informing the debate into the structure and function of such a body, summarised in their paper “Investigations for Improvement”.

It is early days and the direction taken by the HSIB will be dependent on many factors (and as Martin Bromiley points out there is ‘still work to be done by the Government to help establish the Branch on a firmer footing’ and although CHFG has announced the launch there is no obvious sign of a website or contact details for the HSIB), but with focussed leadership and sufficient resources it could herald the beginning of the end to the blame culture, replacing this with one of openness and learning. Given past history perhaps it is not unreasonable to be sceptical and there is no doubt that the challenge is huge but Macrae and Vincent’s paper concludes with some reasons to be optimistic, incorporating the five key requirements they identify for success:

A truly independent, expert, learning-focused, system-wide and trusted safety investigator can be a catalyst for system change. It will be able to identify and explain the most serious risks to patient safety that span the healthcare system, and develop specific recommendations for addressing these risks. It will be able to demonstrate the importance and value of systematic, rigorous and improvement-oriented safety investigation, and provide expert leadership in developing and applying new approaches to safety improvement in healthcare. It will be able to engage widely and openly with patients, staff, the healthcare system and the public on issues of safety, shining a light on what needs to be improved and acting as a tireless champion for the safety of patients. It will be able to model an approach to investigation and shape a new approach to instituting a just culture in healthcare, in which staff feel able to report safety incidents and participate fully in safety investigations—without fearing that they will be inappropriately blamed or punished for actions which any reasonable person might have taken in similar circumstances.