Is system safety finally here?
In March I attended the Global Patient Safety Summit in London, it was a coming together of key academics, policy makers, clinicians and people like myself to share ideas and think about what healthcare needs to do next to improve safety. Perhaps more significantly it coincided with the publishing of the report “Patient Safety 2030”. And even more significantly it brought politicians into the conversation.
Before you get excited I think it’s important to say that healthcare is a long way from developing safer systems at scale, but at last it is receiving the attention it deserves. The Patient Safety 2030 work was developed by a multi-disciplinary and multi national team as an attempt to recognise that whilst we’ve made progress since To Err is Human and Organisation With a Memory, in reality we’re still only playing at being like the other safety critical industries. The report is downloadable here:
In summary it identifies four areas to work on but let me focus on just the first two. It recognises that a systems approach can only deliver the sort of improvements we aspire to in healthcare, especially in the challenging financial times every healthcare system must face. Secondly it urges us to truly prioritise quality and safety through a positive process, not one of blame and punishment.
This clearly chimed with our political masters here in London. The day after the report was delivered by Professor The Lord Ara Darzi, the Secretary of State for Health made a speech in which he said the following:
“To blame failures in care on doctors and nurses trying to do their best is to miss the point that bad mistakes can be made by good people. What is often overlooked is proper study of the environment and systems in which mistakes happen and to understand what went wrong and encouragement to spread any lessons learned.”
The last few months have been a bruising time for the NHS in England with a bitter dispute between the Government and Junior Doctors. This has overshadowed many good things happening at the moment. But there’s still some good things to come. This month we should see the release of the Expert Advisory Group’s report into the new investigation team now known as the “Healthcare Safety Investigation Branch” which will be an important step forward. We should also see the release of the final report by the Health Foundation into Safer Clinical Systems. Both of these expected reports should make significant reference to human factors and system safety.
Finally, if you want to look at something inspirational, watch this short video from Sky News, it lasts less than 3 minutes but manages to combine the obvious “team working” element of human factors with (at last!) the critical importance of design.
Maybe system safety is really getting closer!