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.
Since the inception of the NPSA, in 2001, the agency has worked tirelessly to put patient safety at the heart of the NHS and Dr Woodward reflected on some of the organisation’s most significant achievements – including the implementation of the National Reporting and Learning Service (NRLS). Connected to every NHS organisation in England and Wales, the service has helped to identify common risks to patients and opportunities to improve patient safety, through the confidential reporting of over one million safety incidents per year.
The NPSA’s ‘clean your hands’ campaign has resulted in significant improvements in hand hygiene; patient deterioration has been studied and guidance developed to help ensure quicker intervention; numerous alerts on unsafe medication practice have been issued – reducing the number of deaths associated with medication errors; and the Patient Safety First campaign has led to the successful implementation of patient safety improvement tools such as the Surgical Safety Checklist adapted from the WHO Checklist.
Over the last decade, staff have also been supported by training and information from the NPSA on ‘being open with patients’ and ‘root cause analysis’.
“Because of the amazing work that has been undertaken, by many people in the patient safety field, we now know much more about patient safety than I could ever have imagined twenty years ago. We now know why things go wrong, what should be done and how to put things right.”
Also speaking on the subject of patient safety, Mark Emerton, consultant orthopaedic surgeon, Leeds Teaching Hospitals NHS Trust examined the question: “Violation and migration – why does it happen and what can we do?”
A senior fellow in Quality and Safety Improvement, at the NHS Institute, Mark Emerton is the lead clinical faculty member for the Leading Improvements in Patient Safety course, and has previously been a member of the core team for the national Patient Safety First campaign – as well as a senior clinical advisor to the National Patient Safety Agency.
He asked the audience to consider: “When people do not follow policy, are they being deliberately obstructive – or are there other factors at work? If the latter is the case, we need to understand why people do not follow the rules, so that we can design systems that take this into account.”
“In the real world, we are forced to make decisions on where compromises can be made and hence begin to migrate away from the expected safe zone. We find ourselves in the area of ‘borderline tolerated conditions of use’, as we come up with small changes and adjustments to policy,” he continued, adding: “The problem is that you can migrate further and further away from the safe zone to a dangerous place – and that is what we have to guard against.”
He warned that if we fail to understand the cause of such migrations, we will miss the opportunity for improvement. Moreover, simply punishing those who break the rules will lead to violations remaining hidden. There is a need to find ways of changing the guidelines to ensure they work in the real world, while ensuring a safe and just culture, he concluded.
