The series events which have led to Dr Hadiza Bawa-Garba being struck off the GMC register after being found guilty of manslaughter have brought the management of healthcare errors into the spotlight. In response, Jeremy Hunt emphasised “If we are going to keep patients safe then we have to make sure that doctors are able to learn from mistakes.” It has to be accepted that mistakes are inevitable in complex systems. As the old saying goes, “To err is human.” This does not mean that we should accept everything that goes wrong. Incidents and near misses should always be thoroughly reviewed and it is essential to differentiate between the honest mistake and true negligence. But how to ensure that investigations come to the right conclusions? These are matters which we discuss during our Practical Leadership & management Course of Doctors.
Reviewing the review process
In October 2015 the Care Quality Commission reported on their investigation into reviews being conducted within healthcare stated, ‘In our review of the quality of investigations into serious incidents involving patient care in acute hospitals….. we conclude that while investigation of serious incidents is often seen as one of the most important elements of the patient safety process, this can be counterproductive if not done well’.
They went on to emphasise the purpose of investigations in such circumstances: ‘to identify significant opportunities for learning to reduce or eliminate the risk of the same thing happening again.’ before highlighting the following points:
‘We have observed a high number of investigations that:
- show a lack of skill and expertise in the methodology used.
- do not identify the underlying systems issues that led to the incident; or that leave the reader with unanswered questions.
- There was also limited evidence that patients and families were engaged in the process, or that clinical and other staff were sufficiently involved’.
In the same year the UK Government Select Committee Report stated: ‘The focus of investigations into ‘never events’ was ‘preoccupied with blame or avoiding financial accountability.’
Further pitfalls
Though conducting a review sounds fairly straightforward, doing it well takes dedicated effort and a degree of skill.
One potential pitfall is to confuse correlation with cause and effect. Just because a relationship exists between two factors does not necessarily mean that one is the cause of the other. For examples: when the Czar found out that the most disease-ridden city of the empire was also the city with the highest number of doctors, he ordered the execution of all doctors in the state. A logical conclusion and course of action?
At the other end of the scale the writer Malcolm Gladwell explores the idea in a number of his books that too often we find ourselves drowning in facts at the expense of true understanding. Being able to list off the events which led up to a past event does not automatically mean that you understand what actually caused the event and how to either avoid or repeat a similar occurrence.
Further difficulties arise from the phenomenon of creeping determinism. It can be all too easy to examine an event, establish the trail of incidents which led up to it and to conclude: “How did they not see that coming?” or “Why did they not do something about it before it got to this stage?” This type of thinking is of response is often observed in reaction to everything from terrorist attacks and the outbreak of wars, all the way down to team performances where football pundits assess why your favourite football team lost a goal.
The way forward
The same processes and principles which guide quality investigation into problematic incidents have equal relevance to situations where things have gone well. Why were we successful? What did we do differently? This helps to reinforce the positives rather than simply focus on the negative.
For unwelcome events, the differences between negligence, incompetence and human error must be understood and the true reasons identified.
- True negligence is unacceptable and should be treated as such.
- A conclusion of incompetence leads to numerous further questions before the correct course of action is identified. Were they consciously or unconsciously incompetent? Why was the incompetent person put in this position? Could the series of events been reasonably predicted – given everything else that was taking place at the time?
- Where the cause is human error the next question has to be :”Why was human error possible?” That’s where the true issues are likely lie. And to quote the full version of the the 18th Century poet, Alexander Pope, “To err is human, To forgive, divine.” This may be easier said than done than the patient or their family who have suffered harm as a result which puts understandable pressure to find answers.
The CQC’s report concluded, ‘it is important that providers develop expertise and invest in the tools needed to properly investigate, so that the right lessons are learned and shared.’ What steps are you taking to improve your skills in this area?
Stephen McGuire – Head of Development
