Incidents and investigation
If individuals fear the personal consequences of reporting incidents they are involved in, then they are less likely to be open about mistakes. Opportunities for learning from those incidents are lost, nothing is improved and similar incidents happen in the future. On the other hand if people feel that they will not be held responsible and only good will come from reporting incidents, then they will be much more likely to do so openly and honestly. Future harm is then avoided, preventing the future suffering of patients, their families and often the professionals involved who become secondary victims. Not only incidents but also ??near misses??, where bad things almost happen, are more likely to be reported, allowing problems to be fixed before anyone is harmed at all. Furthermore time less time is wasted dealing with the consequences allowing nurses and doctors to focus on patient care. There is also a massive economic case: the NHS currently has set aside £?28 billion for medical negligence liability costs alone. The benefits of a learning culture are enormous, but it needs to pervade all levels of the healthcare system for it to happen.
A key issue facing the healthcare system is therefore how to embed such a learning culture, and move away from a blame culture. CHI+MED has looked at the way incidents are reported, the way it is investigated and developed new models to understand accidents. We have also looked at how media report incidents and how it might be done more responsibly.
Improving reporting forms: redesigning the clinical incident reporting form to make it fit for purpose
We have identified serious flaws in the clinical incident reporting form that healthcare professionals fill out when they realise someone has made a mistake, that could affect the safety of a patient. The forms currently used in the NHS do not allow easy and quick reporting at the point of care nor do they support learning from incidents. We have developed an improved form that encourages those filling it out to be more open and honest about mistakes. These changes are based on a combination of past research, the opinion of healthcare professionals and the best features of existing forms.
Writing incident reports
Working with NHS England, we have reviewed over 8,000 incident reports about the use of medical devices. We have demonstrated the limitations of the reports for learning about design, training and practice about infusion pumps.
In particular the free text fields of incident reports are open to many interpretations which limits their value for deep learning beyond the organisation (though they may have value for spotting trends). Reports also typically focus on local factors without regard for wider policy implications. This has led to our making recommendations to NHS England guidelines for training people in writing incident reports.
The language of incident reports
We have also considered the language used in incident reports. We particularly focused on how incident reports that had been classified as user-error within this sample differred from those that were not. When reporting incidents that are classified as involving user-error the reports are significantly shorter than those classified in other ways. They are also significantly less likely to be written in the first person, from the reporter’s point of view. They are also far more likely to write in a passive style, and avoid naming anyone, even patients. Given user-error classified incidents are classified as such because the error is linked in some way to a person, or user, we would expect to see the opposite. This suggests that those writing the reports are actively removing themselves and others from the report in the language they use, and this may link to a blame culture. This work suggests that techniques from linguistics may help understand aspects of blame culture and even track a changing blame culture in healthcare over time.
Hot Cheese Model: a new way to explore the impact of bad design on incidents
Poor design of medical devices has caused many incidents where patients have been harmed. However, design as such is not prominent in existing models of accident causation, particularly Reason’s widely-used Swiss Cheese Model. The new “hot cheese model” highlights the impact of bad design on incidents in a simple, flexible and memorable way. The model sheds light on this hidden issue, and supports risk analysis and risk management in safety critical fields, including aviation, engineering, and healthcare. If it were adopted widely it could lead to further incidents being prevented, saving both lives and money for the healthcare system.
Responsible media reporting
We have analysed the media reporting of three incidents involving the deaths of babies to understand its place in a learning culture. The work suggests that the way the media report an incident can affect whether the underlying problem is corrected. Before investigations, such as coroners’ reports or criminal investigations, are closed balanced reporting is key. Hospitals need to be open and honest rather than suggesting there isn’t a problem or that it is restricted to a single ‘bad seed’, if they are to encourage reasoned reporting. They should make clear recommendations of how the hospital as a whole can change to prevent similar incidents occurring in the future.
Evidence (justice system): trial evidence
A CHI+MED research acted as an expert witness to highlight that the medical device computer records used in a trial were unreliable at which point the trial against two nurses collapsed.