Driving passion for patient safety

Patient safety was high on the agenda at the recent annual congress of the Association for Perioperative Practice – with workshops on human factors, sessions on why people do not to comply with safety rules; to discussion of safe staffing levels in theatre, in the face of financial pressures. This year, the Daisy Ayris Lecture marked the end of an era, however, with an emotive and inspiring talk by one of healthcare’s leading figures in the field of patient safety. Dr Suzette Woodward, director of the National Patient Safety Agency (NPSA), gave a personal reflection on ‘leading staff through a defining moment’ – as she dealt with the announcement of the closure of the NPSA, as well as a moving account of an incident, which took place early on in her career, that drove her on to become an influential and passionate patient safety champion.

A defining moment

An author of national guidance, including Seven Steps to Patient Safety, Dr Woodward has a track record of rolling out large-scale change programmes to improve patient care and was the implementation director for the Patient Safety First campaign. By the end of the campaign (2010), 61% of acute Trusts had patient safety and quality as their first agenda item at board level – a significant increase on 2009, when the proportion was just 18%.1 She also designed the ‘10 for 2010’ patient safety programme, which set out to reduce harm by concentrating efforts on ten high risk areas. This included the prevention of: pressure ulcers, incorrect dosage of insulin and falls; as well as early recognition and response to deterioration. A member of various Department of Health groups, including the National Patient Safety Forum and the National Quality Board, she has a Masters in Clinical Risk and a Professional Doctorate on Patient Safety, focusing on the factors which help and hinder sustained implementation. However, earlier on in her career as a senior paediatric intensive care nurse, Dr Woodward experienced, first hand, the devastating impact of a patient safety incident on all those involved – from the patient and their family, to the staff responsible for delivering their care. This defining moment was to change her life forever: “My role on the ICU meant I was caring for children from a few weeks old to teenagers – they and their families were at the centre of my world. I loved my job – I enjoyed the close bond that could be formed through one-to-one nursing. It was all I ever wanted it to be,” commented Dr Woodward. “We dealt with children with numerous but life threatening conditions. There was equipment and noise everywhere – ventilators and monitors bleeping, suction machines wheezing and gurgling. I was on night duty, I was in charge, it was my fourth night and I was exhausted. I didn’t cope very well with nights and had difficulty sleeping during the day. As each day and each night progressed, I became more and more sleep deprived,” she recalled. Early on in the evening, her task was to be a ‘double checker’. This was where the drugs were drawn up by the bedside and the nurse in charge ‘wandered about’ double checking. The children were often on several different drugs, she explained. “It was a very sporadic affair; there were constant interruptions and distractions – sometimes in midcalculation. It was an attempt at a carefully choreographed dance from one patient to the next,” she continued. “At around 10 pm, I went to the bedside of a little boy who had been on the unit for a while. I remember him well – he had beautiful blond hair. One of his drugs was new to him, new to the bedside nurse and new to me. The drug was to be calculated on his weight, to be diluted with saline and diffused over time. We were constantly interrupted, but we eventually set up the infusion and I moved on. “Midnight came and we were joined by a group of doctors. We were reviewing the boy’s chart when one of the junior doctors approached me. He took me to one side and said: ‘That infusion does not look quite right. It looks too concentrated. How much did you use?’ We worked out the answer to that question – it was ten times the prescribed dose. “Even today, I feel my heart pounding at the memory. I was rooted to the spot for a few minutes, but it felt like hours. Impossible questions were asked of me, by others, but also by myself. ‘Where did you go wrong?’ ‘What was that buzzing in my ears?’ ‘What were you thinking?’ ‘Why did I feel so sick?’ ‘Why did it happen? ‘Why is everyone staring at me?’ ‘Was it a calculation or calculator error?’ “I felt like I didn’t even know my own name by this point, let alone what had happened. This was midnight and I had another eight hours to go before the end of the shift. We needed to ensure the child was ok and I had no idea of the consequences. We also needed to care for all the other children as if everything was normal. But it was far from normal. The bedside nurse blamed me, the senior nurse on duty the next morning blamed me, I blamed me. I was devastated. Life was never the same after that. This was one of my first key defining moments.” The morning after the drug error, the young Suzette Woodward was called to see the senior nurse of the children’s division. She was told that ‘she should have known better’ – a note would be placed on her file and, if it ever happened again, her role on the unit would be called into question. If it happened three times, she would be sacked for incompetency. “There was no investigation, no discussion between the staff as to why it happened, it was all about who was at fault. No one spoke to the parents of the little boy, and all the staff on the unit knew about the error and how I would be dealt with. If anyone had thought about speaking up before the incident, they definitely wouldn’t have wanted to after. Most importantly, no one learned from that incident to prevent it from happening again,” said Dr Woodward. Many years later, on the 3 January 2003, she found herself standing at Maple Street, outside the headquarters of the NPSA, on her first day, full of expectation and full of hope for the future. She explained that she was initially motivated by the desire to make it harder for nurses to make the same mistake that she had, all those years ago. It is not just a professional desire to make care safer that has driven Dr Woodward to make a difference – for her, it is deeply personal: “Not only have I been the cause of harm, but I have been on the receiving end of harm, and I have seen friends and loved ones affected by harm,” she commented. “I am still that nurse, all those years ago. The desire to care runs through my veins. But I am much wiser now. I learned that what I experienced had a name – patient safety was much more of a problem than I ever imagined. “Over the last decade, we have gained an in depth understanding of the contributing human factors associated with patient safety – including those associated with medication errors, like the incident that I was involved in. “We also understand the importance of design – including visual clues, clear packaging and labelling. In my case, the drug was new to us. I accept that we should have stopped and looked it up in more detail, but we didn’t pick up on any visual clues to the concentration of the drug within the syringe. “In addition, we recognise the importance of understanding calculation risk – paediatrics is fraught with risk because of the mathematical calculations required, relating to weight and dilution in saline. The most frequent type of error using calculators is decimal point misplacement, leading to ten times or hundred times the dose being administered. I am told this is a classic error. I never wanted to be part of a classic error. You should always have an independent double check – not a confirmatory double check.” The concept of human factors is a science that all healthcare workers should be studying, she asserted: “Only then will you truly understand how the human fits within the system and how that system either supports or fails the individual. Simple things like distraction and fatigue are major contributing factors in errors in practice and calculation. We need urgent awareness of these issues,” she warned. Culture is also important, in her view, to ensure that staff and institutions learn from mistakes: “We need to have an open and just culture... not one without accountability, but one that ensures that people are treated fairly and are supported when they make mistakes. Punishment buries problems underground. “The challenge is for us to take what we know and act boldly, to finally eliminate the harm associated with factors such as patient identification, communication, test results going missing, wrong doses of medication and inaccurate patient observations.”