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We promote what we tolerate.

It was very good to see so many old friends at NAMEM (National Association of Medical Education Managers conference) recently and particularly put faces to those names!

What will probably stick in all our minds was the talk by Dr Victoria Bradley on her culture-changing experiences and her successful challenge of an unsafe clinical department situation. It was a pleasure to hear that her bold actions brought real front-line improvements in staffing levels and patient care.

She had to overcome her concerns about ‘whistle-blowing’ and potential repercussions and having done so was rewarded and thanked by very senior management in her Trust. Quite right too. But sadly this is not a frequent occurrence regarding the happy ending.

Frequently we hear course delegates stating that they don’t feel confident in raising concerns and in some situations don’t feel anyone is listening and nothing will change.

However how does this fit with duty of candour? We promote what we accept and tolerate. Turning a blind eye is simply not professional.

However the multiple reasons why so many of us don’t challenge unsafe or unprofessional situations are understandable and often a facet of our very essence of being human, such as the Fight, Flight, Freeze response. We have recently run several courses when admissions of passive behaviour have been manifest. But we at Atrainability have found we can help rebuild that confidence and re-motivate team members to speak up with appropriate persistence.

Courses combined with individual and team coaching helps build more-effective safer team-working. We are constantly developing new material, with a focus on advanced Human Factors looking at Stress Solutions and dealing with difficult people – including colleagues!

 

 

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Human Factors - common sense made conscious

We have begun a major training programme at a large private healthcare provider in London where all staff are attending an initial very short introductory module on Human Factors. 
The content is limited to why the subject is relevant to them all, some explanations of why we are all fallible and a few practical takeaway tools on how to try and avoid things going wrong. The long term plan is to continue to work together and build a sustainable high reliability organisation with safety at its core. 
Later in the Autumn it will include training trainers and champions to embed safe policies and procedures and seek to support staff.
The Director of Nursing had been actively seeking such training and has been a fantastic advocate, but the clincher was getting to present to the Board. 
The Chief Executive is a smart no-nonsense lady. I asked her and her senior colleagues if they knew what Human Factors is. Her instant response "well it's just common sense". Of course it is, but the trick is how to bring that to the conscious brain when faced with all the pressures and hazards of everyday work life.
That is where we seem to be helping judging by the feedback from the attendees. They love the simple messages and that we are talking their language.
Mind you it's quite a challenge with each class containing up to 30 from every area in the Hospital from finance through reception to ITU and theatre teams.
It is fun, engaging and at first sight seems to be making a tangible difference. 
Here is an example of unsolicited feedback from an ODP in paediatric theatres:
 
"I just wanted to say how much I enjoyed the training session. I think Ben delivered a really good session and I personally learned a great deal. It has given me some good ideas of ways we can improve our day to day practice within our department and has inspired me to look further into the human factors training principals and background.
If you could pass my thanks on to him that would be appreciated."

The icing on the cake, though, is that the Executive Board are all attending alongside all the 600 staff. 
Now that shows what leadership should be and will undoubtedly have a profound positive effect.

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Reporting Near Misses - Untoward Incident or Known Complication?

The benefits of reporting near misses are surely beyond dispute. Each close shave is a learning opportunity which should be shared with others. Does every doctor need to experience problems first hand and patients endure possible harm in order to gain a high level? 

I have recently heard of an incident in maxilla-facial surgery which has disquieted me. A senior consultant decided to perform two lengthy operations in one day and incur a significant overrun to the detriment of the theatre teams. It had been possible to ask a fellow senior surgeon to take on one case and indeed such an offer had been made. The offer was impolitely refused.
The second procedure was commenced at 4 pm and involved a neck dissection. Unfortunately a small tear was made in the lower end of the jugular vein where it joined the subclavian vein. The anatomy was non-normal in that the vein was above the clavicle rather than under.
 
There was considerable haemorrhage which was not controllable. Vascular surgeons were called and the vessel was approached from the anterior chest wall, but were unable to control the bleeding. Eventually orthopaedic surgeons were called to divide the clavicle and the tear was over-sewed. The patient lost 18 units of blood and the cell-saver was used successfully to replace lost blood. The anaesthetist performed very well in difficult circumstances.
 
What could be learned?

The surgeon did not consider this a reportable incident and indeed was most vociferous in wishing it not to be reported. One must ask why? Does it indicate fear of the local culture? Or is it something more ego-driven?
 
What would you consider the professional response?
 
Surely if this is a recognised non-normal anatomical situation it should be shared to help junior doctors learn to avoid it happening to them?
 
How can we make it ‘safe’ to report near-misses and move the whole culture closer to the aviation model where incident reporting is actively encouraged? 

We specialise in training for debriefing to learn. Blame serves little useful purpose unless people are wilfully ignoring rules and due process.
 
Training utilises the greatest resource – a team member who may have made a mistake despite trying their best not to. What a resource to help the whole organisation learn! Shame to waste it.

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Lighting the Blue Touchpaper

Lighting the blue touch paper

The trainers are excellent, engaging, knowledgeable and enthusiastic. The Training was brilliant and it has really set fire to my personal blue touch paper. It has made me think about how to look at things differently, and as a result I revisited a policy I am working on; so that lessons learned can be applied in a more meaningful, informative way, rather than staff feel they are being blamed and penalised.

Project Lead, Safe Services, Cheshire and Wirral Partnership Foundation Trust

This was feedback from this week when we presented a train the trainer course for Cheshire and Wirral Partnership Mental Health Trust. This is the second in a series aiming to bring about sustainable improvements in a Zero Harm campaign. Other selected comments from the evaluation sheets:

 

·         Very eye-opening course which used common-sense ideas & delivered them in a structured constructive manner

·         Thoroughly enjoyable & thought-provoking. Ought to be part of mandatory training

·         Need more staff from clinical area to attend this training to enhance knowledge, practice, empower them.

·         Hope the Trust fully embeds this learning into the culture

·         Excellent course – pragmatic, common sense & gives words to describe how I feel about potential change culture

The initial response has been fantastic.

 

At the end of Day 1 one of the delegates from the first course spoke passionately of the changes she now felt able to make. She really enthused her colleagues.

Most startling and pleasing was to hear from her how what had begun as a disciplinary inquiry became a lesson in learning and understanding the good reasons why a staff member had deviated from procedures in efforts to do the best for the patient or service user.

We offer a flow chart based on that of Professor James Reason that clarifies when training is the correct treatment for rule violations and those rare occasions when disciplinary action is necessary.

In simple terms if you are not employing psychopaths or sociopaths in your teams, then most errors are unintentional or made with good outcomes in mind.

Understanding why and how errors are made at the Human level is so beneficial to creating a resilient high performing sustainable system.

It could even mean a redesign of some procedures. Many of our clients are doing that now.

If it results in a reduction in avoidable harm it must make sense!

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Real positive change at the frontline

The Patient Safety Congress is in Liverpool this week, and the subject of Human factors is to the fore. Back at the front-line we are delighted to report that feedback from nursing staff at one department we have recently trained has reported real improvements in team practice and hence morale -

"Since we attended the Human Factors course, we now, as a department have daily meetings to discuss ‘job’ allocation, so that everybody is aware of what is expected of them during the day. This is working particularly well, everybody is now focussed on what they need to do, rather than overlapping, and tripping over each other,

We also have a  debrief at some point in the day, to ensure everything is  still running smoothly, and talk about any problems or situations that may have arisen through the day. All the nursing staff are very happy implementing this, and wish as a group to say thanks again."

This was a result of a whole department enjoying a full day of class-based training consisting of:

Ø  Introduction to Human Factors

Ø  How & why we make errors

Ø  Situation Awareness

Ø  Decision Making

Ø  Communication

Ø  Dealing with difficult people

Ø  Leadership & team-working

Ø  Briefing & Checklists

Ø  Debriefing for Learning

It was a full day but enjoyable all round. Not bad when you consider it included the whole range of staff from clerks, reception staff through nurses and ophthalmologists! Phew.
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Safety in Neurosurgery - a successful Human Factors intervention

 
Five years have now passed since the Atrainability team helped a neurosurgery unit in the North East of England overcome a string of major wrong side errors. 
Prior to our training and coaching intervention their had been a rate of 1 in 300 wrong side errors. The surgical Lead had instituted a 'knife' check - a check that everything was as it should be pre-knife to skin - but then another error occurred.
 
Atrainability trained almost all the team members in how to avoid and trap errors and particularly how to assert the need to brief the team and check all appropriate items, including of course surgical site. One or two senior team members were unable to attend but those who did were trained in dealing with colleagues who were not keen on such non-technical matters, politely but firmly.
This was all before the WHO checklist had been mandated.
The result is now five years without another incident. Time between error is the measure and is statistically valid.
 
It is a sad fact that many organisations contain 'difficult' people who feel their skills are being questioned. Not everyone is open to comments about their behaviour. It is not an accepted part of the culture in many areas of healthcare. But if the team stand united and firm, challenging individuals can be handled without any unpleasantness. 
 
Although not part of an academic randomised control trial, these results are notable and a splendid testament to what can be achieved in the name of patient safety.
 
As the Surgical Lead said - "The error you have to prevent is 2 years from now, out of hours, when you are on holiday and a locum surgeon you will never meet is operating at night with a junior anaesthetist and newly appointed scrub nurse."
 
For those still sceptical, consider the cost of training against the cost of compensation and litigation. It is an investment well worth considering.
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Debriefing? Missed opportunities to learn from near misses.

The accepted theory of Threat and Error Management 1,2  indicates that there is tremendous benefit to safe teamwork  by attempting to avoid all possible problems in advance. From this has come the practice of team briefings before surgical procedures. However not everything can be foreseen and our memories of what has been discussed may be erroneous due to such as the passage of time, fatigue, hunger, personal stresses or just ineffective communication. For this reason the WHO Safer Surgical Checklist has been mandated and its use is accepted across healthcare surgery. However it seems from our experience that compliance is less than 100%. One of our Atrainability team has just had an operation where the WHO paperwork does not appear to have been completed and performance of the checks themselves somewhat suspect. Fortunately no harm has apparently occurred.

However the greatest opportunity for improving safety is a simple debrief. The front-line team are the most under-utilised source of learning from success as well as failure.

A recent investigation of a particularly tragic case highlights the resistance to learning from everyday events. Our team was taking part in a research project in a major hospital in 20083. A scrub nurse taking part in a neurosurgical procedure was asked to hand the surgeon a syringe of saline to wash out the operating site in the cranium of a child. The surgeon did not remove his eyes from the microscope and did not check the syringe. It so happened that the nurse was under training in this specialty and had mistakenly handed a local anaesthetic. Fortunately the error was trapped by the supervising scrub nurse who handed her the correct saline. Both syringes were externally identical – no colour-coding. The Consultant surgeon was completely unaware, but the Anaesthetist was fully aware.

Within 2 years of this a tragic but similar incident occurred in the same hospital. http://www.bbc.co.uk/news/uk-england-london-25916336

At the time of our observation the Consultant Anaesthetist declined to debrief with the team because "nothing happened".

No direct conclusion can of course be drawn but overcoming resistance to learning from near misses (near-hits?) should be a professional response.

Encouraging debriefing and responding appropriately to warnings of unsafe situations, avoiding unnecessary blame, must be the way forward for management and multi-disciplinary teams.

References:

1) On error management: lessons from aviation - Department of Psychology, University of Texas at Austin, Austin, TX 78712, USA Robert L Helmreich professor of psychology helmreich@psy. utexas.edu BMJ 2000;320:781–5

2)     Culture, Error, and Crew Resource Management Robert L. Helmreich, John A. Wilhelm, James R. Klinect, & Ashleigh C. Merritt, Department of Psychology The University of Texas at Austin

3)     Catchpole, K, Dale, T, Hirst, G, Smith, P, Giddings, A.(2010). A multi-centre trial of aviation-style training for surgical teams. Journal of Patient Safety 6(3), pp. 180-186.

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The Human Factors Message is spreading

It is great to spread positive news about the growth in adoption of Human factors. Increasingly Healthcare organisations, NHS and private sector are adopting training and process redesign with a view to make care of patients safe by design not by luck.

Atrainability have been engaged to train Trust-wide trainers and Champions in several healthcare providers. Here are some anonymous examples:

·         One of the top-performing Trusts in the NHS in England is offering Atrainability Human Factors Train the Trainer courses to all its trainers – clinical and non-clinical. Almost 50 have attended and we have a waiting list. They are tasked with embedding safe practice and checking procedures for sense and practicality.

·         A major private healthcare hospital has engaged Atrainability to train the entire nursing staff across all wards and units.

·         We have recently worked with a clinical simulation unit and then subsequently with the same Trusts Maternity Unit using advanced simulation debriefing techniques.

·         Training and coaching in a Medical Assessment Unit has revealed solutions to blockages in patient throughput from A & E or GP input to ward or discharge to home.

·         We are working with a Mental Health Trust on smarter procedures and checklist design for such as safe monitoring of in-patients and service users including early recognition of potential slips, trips and falls.

·         A major cardiac centre has engaged Atrainability to help build safer, more resilient teams in the ITU. The same centre has changed Operating Theatre procedures around Briefing, Checklist usage and Debriefing with our training and coaching support.

·         As a sign that the knowledge and skill of safe Human Factors working is spreading we are delighted to be able to streamline the SMART anaesthetics course that we run with the team from the Difficult Airway Society http://www.das.uk.com/course/smart

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Never events and those pesky Human Factors

I’ve recently heard of several recent never events and thought I would share the Human Factors elements as reported to me.
In a Maternity unit a vaginal swab was left in post-delivery and the doctor was  found guilty by the Root Cause Analysis because he had failed to follow standard procedures. But looking at incident in more detail it transpires that he was interrupted by 4 other urgent cases in the unit while trying to deal with this one. The dangers of interruptions and distractions are well recognised and we should all work hard to reduce and ideally eliminate them.
You could argue that this is another side-effect of short-staffing perhaps?
 
The next was about a junior doc who had ignored the Time Out check and had helped himself to local anaesthetic and scalpel behind the scrub nurse. Instead of the trigger finger release planned he went into the wrist as for a carpal tunnel procedure. What was stunning was that this was 18 months ago and I know of an identical error at a high performing Trust 10 miles away – this Summer. It is the responsibility of all the team to ensure correct application of the WHO checklist. Many times we hear of how use of the checks slows down the flow of the day especially in small day case units, but this is what happens if you don’t. No-one would be happy to take off in a plane where the pilots hadn’t checked everything that mattered …..!
 
The latest report into Barrow Maternity unit make unpleasant reading too http://www.bbc.co.uk/news/uk-england-cumbria-25322238. 
‘Insufficient supervision’; ‘inadequate training’; ‘failure to monitor CTG’ etc. Bad people? Maybe but probably a failure of training. Nurses, doctors, midwives are not normally chosen from the ranks of psychopaths, but in order for us all to adopt safe procedures we need to know the rationale. The investment in training pays you back in every way – the human cost – patients, relatives etc; retention of staff due to improved morale and non-acceptance of poor behaviour; reduced cost of case reviews and CNST payments.
 
To find out more about our Human Factors training courses click here.
 
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The Chandelier Principle

I’ve had a great week – 3 days running a train the trainer with Humberside Fire Service and their offshoot HFR Solutions. Our new partnership will help to spread the Human Factors message across Emergency Services and Industry in the Humberside region and beyond. Great team there with imagination and vision, coupled with the energy and intelligence to make a real difference.

Yesterday, December 5 Atrainability exhibited and ran a MasterClass in changing healthcare safety culture.

Today I am off to meet Air France and discuss SportsTec high quality video recording and playback software. British Airways have just bought this for installation in their simulators. It is without question the most fantastic training aid.

In the MasterClass I referred to teams as being the light-bulbs that have to want to change in order to improve safety behaviour.

I just woke early with my own light-bulb moment.

A successful organisation is like a chandelier with long life bulbs. They require less energy, they cost more to begin with, but they last longer. They shine out like a beacon and bring light around them. They work.

A less successful organisation is like a chandelier with many bulbs out. They run old fashioned incandescent bulbs. They fail frequently and the overall effect is dim. They don’t shed much light.

Training is not cheap – up front. But it makes a lasting change. It brings long term excellence that sustains. Successful organisations, be they NHS Trusts or commercial organisations recognise this.

Nothing is so powerful a training aid as watching your own performance and hearing your own words. It helps the light-bulb want to change.

Atrainability can help to spread that light.

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Embedding Human Factors knowledge and understanding to combat avoidable harm

I am fresh back from 3 days of Train the Trainer for Northumbria NHS Foundation Trust, one of the top-performing Trusts in NHS England. I am invigorated and full of the joys because here we have a healthcare provider that knows how to maintain high quality resilient compassionate care.

Atrainability increasingly work in the North East of England. Previously Safer Care North East recognised the crucial importance of human factors in dealing with avoidable harm and engaged Atrainability to educate a multitude of influential team members across what was then the Strategic Health Authority. Happily the enlightened ones have found positions of influence and are carrying on the plan.

Northumbria Trust has realised that having a profound embedded understanding of Human Factors within every department can help to avoid, trap and mitigate potential costly harm within the system.

This week I have had the pleasure of the company of a diverse group of enthusiastic, intelligent, committed professionals and judging by their feedback comments changed their outlook. We are all hoping this will have impact on how staff are trained, how procedures are designed and implemented and how a safe just culture is sustained.

Here are some of the course comments:

· “fantastic course”

· “my outlook on life has changed forever! I am looking at life through Human Factors glasses. I’ve also learned a lot about myself. I would thoroughly recommend this course I have honestly never got so much information and enjoyment from a course before!”

· “Relaxed, informal but very informative, thank you”

· “I will develop a 1 day error-proofing training course and invite colleagues to attend. My aim is to share and spread the message across the North East so that people become aware of their behaviour and act appropriately. This should result in an increase in reporting and a reduction in errors.”

 


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The importance of Self Awareness

I've just been reading Daniel Goleman in his blog about teaching emotional intelligence skills to school kids as a method of reducing bullying and other anti-social behaviour. Self awareness alone is fundamental to effective working with others and seems to be lacking in some cases. I will explore more of the Emotional Intelligence elements in later posts.
 
As Jung said "everything that irritates us about others leads us to a better understanding of ourselves".
 
The issue is complicated by the shortage of skills in management and fellow team members  to adequately deal with those lacking in this insight.
Educating emotional intelligence has been standard practice in many schools here in the UK for some years. Clearly there will be variation in how well the message gets through. Having personally witnessed some  inappropriate behaviour by a minority of clinicians, and nurses in some cases, over the years one does wonder whether there should be more emphasis on EI in the medical school curriculum or indeed perhaps it should be part of the selection process for anyone entering healthcare employment.
 
In my time in aviation the 'person specification' was changed from pure piloting skills alone to people who could work well with others.
OK some outliers always sneak under the wire but generally the culture of the profession has changed for the better. This is in large part down to a focus on the customer but also on the recognition that effective team working makes for safer performance. It has been stated often that over 70% of aviation accidents are due to human error in one form or other and rarely do any airline crew work alone be it in flight deck or cabin or even on an engineering team.
Aircrew get properly appraised 3 times a year on their technical and non-technical skills and must by law be refresher-trained on both every year.
Safe sustainable  effective working doesn't happen by chance it is the product of investment in training and hard work. Plus having a supporting culture that encourages effective emotionally intelligent behaviour and acts to put a stop to the inappropriate behaviour. 
Now that Sir Bruce Keogh has reported in a profoundly sensible manner perhaps we can all benefit. The news that Sir Mike Richards is recruiting an 'army' to inspect and report on sites is copying the age old 'wife and kids test'.
Back to when i was a Training  Captain in the airlines -would I let this pilot fly my family?
Works for me!

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Junior Doctors training

This morning (1st July 2013) on BBC Breakfast TV (0722 for those with BBC iPlayer) there is an extensive report on training junior doctors at Newcastle University. The focus they mentioned was Care, Compassion and Dignity - excellent, just as it should be. Dr Matthias Schmidt understands the need and the issues as do many of his colleagues. "If I don't set a good example we won't be looked after properly in the future. Of course.
 
There is also associated research at Cardiff and Dundee Universities. Lynn Monrouxe from Cardiff was interviewed as well as an anonymous junior doctor- too concerned for his own future to be named. He spoke of the dangers of "not showing due deference to seniors"!
What was a pleasure was to hear one of the co-authors, junior doctor Stephanie Wells speak of learning from the poor experiences as well as the good ones. There are indeed silver linings.
 
However as they went deeper more troubling comments were made about regular observations of poor behaviour by senior doctors, some of it potentially dangerous to patients and certainly demonstrating lack of concern about patient dignity. One comment was about poor hand washing - did Semmelweis teach us nothing? Another was about being requested to perform an unconsented procedure while the patient was anaesthetised. Aren't these simple basics? Hippocratic Oath anyone?
 
Abusive behaviour was a significant facet of their training. Then they mentioned the 'H' word - Hierarchy and the potential career-limiting move of reporting such unsafe and inappropriate behaviour. Let's face it, that isn't limited to juniors! sadly.
 
What on Earth is going on? Why do some senior clinicians think this is an OK way to behave? Is it repeating the behaviour they experienced as juniors? Is there any excuse? 
 
We regularly run Human Factors courses for FY2 doctors across the country and always ask - "could you challenge every one of the senior doctors that you work with?" We have never had a positive answer to that. Indeed there was a major research programme a couple of years ago in the US where 100% of junior doctors stated exactly that - they could not challenge every senior.
 
We now ask the following question - "do you want to be one of the people that others hesitate to challenge when you qualify as a Consultant? If not now is the time to think about adopting safe open behaviour."

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Workshop feedback 01

This is the reaction to one of our training days for the NHS Wales National Leadership Programme last week.

“I also attended the Human Factors Training on Thursday afternoon.(which incidentally was a brilliant afternoon and must be fed back effectively to staff who weren't lucky enough to be there) This is the area i work in and already the practice of the WHO checklist has been introduced and has seen great benefits in the Operating Theatre. 
However there are still improvements to be made and all grades to realise they have a duty to be involved, and as Denis Campbell stresses it is a tool that may need changing if the professionals who are using it feel it is not working, as in the Aviation business it has been transformed many times over the last 40 years. It has the ability to be brilliant if everyone comes aboard. 
The advantage that the aviation profession have over us is the Black Box, where every bit of what went wrong is recorded, so they know exactly where things went wrong and precisely at what point. We do have documentation and some equipment that holds data, but a lot of our errors are gathered like pieces of a jigsaw and not always 100% accurate. Communication and Reflection are our biggest tools and Horizon mirrored this with the scenario of a failed airway.(This again is a brilliant piece of work). Through all our roles we can find examples of things that went well, could have gone better, went wrong and must always reflect and learn from these and use this experience to pass on. 
An honest and open approach is one we must adopt unlike the Politicians!! I again ask the Managers to come out from their offices and look at the Work force i.e the Human Factors that are contributing to the patient care that is being delivered, all levels within the Health Board need to examine their behaviour towards patients and staff, as Denis Campbell said you don`t want to change someone`s personality but they may need to change their behaviour towards a patient or Team members. 
If staff are happy in their work, patients may have a better experience, if checks are done it should be a safer one too!!Its not rocket science, its so achievable if staff felt cared for this would definitely have a good effect on the morale and to the working day and in turn be really good news for our patients!! Sometimes we become so bogged down with all the politics we forget the basics and that is Care and this goes for patients and staff!! 
One of the exercises that we did as a group on the Human Factors presentation was "What makes a good day" and "what makes a bad day" Have a think with your Team members you may be surprised!! We can`t get out of this mess but we can hopefully make the best of it!!
We in Theatres are working on it!!!!!!!!”

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Blame or learning?

Blame or learning?
On a recent course a consultant clinician told me of a colleague who had made a genuine error and patient harm had resulted.
The clinician went to their own management and told the tale against themself with the intention of sharing learning and stopping the identical thing happening again.
The treatment they received can be described in a couple of words - blame and humiliation. 
 
Result - never again will that sensible honest professional ever confess. 
 
The more tragic result is the loss of such a powerful educational lesson.
 
The real lesson from high reliability professions is to seek to learn from every possible opportunity.
 
We get told these tales all the time on courses, where we have explained how errors occur and what the barriers are everyday to open communication and defeating inappropriate hierarchy.
 
Healthcare professionals all seem to have horror stories of their own. Some where they have committed the error, some when they have failed to intervene. There is so much learning out there. The vast majority appear to be human factors related. What a wasted resource. 
 
With training, management and teams can learn to shift focus towards a learning culture rather than blame. The result? An open reporting culture, with better communication and less repeated mistakes.
 
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How to avoid mistakes in surgery Horizon 22 March BBC 2

How to avoid mistakes in surgery Horizon 22 March BBC 2
 
The programme itself was very well presented but left the biggest question unanswered: If the evidence for using WHO Safer Surgery checklists is so compelling and use has been mandated, why do so many clinicians still refuse to use it? We are currently engaged by three Trusts that have problems with compliance with use of the checklist. They are not alone.
 
I ran three courses for doctors of various specialties this week gone with about 50 doctors in total. Each of those courses had at least one who expressed reluctance to use the WHO checklist, at least at first. In a way you cannot blame them. If their Trust introduced the checklist by email, as so many did, can you wonder at it? 
Treat people like children and they may just act like them. 
 
We find that treating healthcare professionals appropriately, listening to their concerns and worries gets buy-in. Also explaining what checklists are for, how to use them and particularly what can happen if they are used but not correctly can produce greater willingness to comply. 
In aviation the Spanair MD-80 crash at Madrid in August 2008 resulted ultimately from the crew not performing the pre-take-off checks correctly. The flaps were not set and the result was a disaster that killed 154 passengers and crew. http://www.fomento.gob.es/NR/rdonlyres/EC47A855-B098-409E-B4C8-9A6DD0D0969F/107087/2008_032_A_ENG.pdf
 
Similarly the Air Florida crash into the Potomac river in Washington DC in January 1982 was caused by incorrect checklist usage – the engine anti-ice was not selected on in severe winter weather. The engine intake probes were iced resulting in an incorrect (overreading) power indication. The aircraft accelerated too slowly, failed to get airborne and crashed into the bridge and the river.
http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR82-08.pdf
 
That’s the issue for aircrew, if they screw up there is a good chance they will die. That tends to get their attention.

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Course comments March 19

Course comments March 19
It is a delight to read the comments of the course I have just presented to just 6 middle grade doctors. The big question is where were their colleagues? 
Comments from today - “The things I learned in the course are all very practical and make sense. I now realize that in addition to technical competence, how important a part human and social factors play in the outcome of various situations. Proper understanding of human factors situation awareness, decision making process and team working can make a huge difference in the outcome of difficult incidents.”
Another “a very memorable and enjoyable course, very important for NHS employees to attend – to improve safety and relationships with colleagues. I plan to perform briefing, checklist and debriefing for my bronchoscopy list”.
My favourite is “Fantastic! Let’s get the Managers and Chief Exec on this course too”. That is a comment we often hear. However when one of our SHA clients invited Board members to a special day about a year ago – how many do you think turned up? Just 2 non-execs. How many apologised for the no-show – none.

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Zero Tolerance on Error

Zero tolerance on error

Jeremy Hunt was quoted over the weekend saying that there should be zero tolerance of error and comparison with the aviation professions was the starting point.

Let us be clear, in aviation error is expected throughout the system. But thorough training is put in place – initial and recurrent – and assessment of non-technical skills performance. All technical training has the non-technical aspects blended in. But also there is constant vigilance for system problems which damage the Safety Culture. All incidents and near hits must be reported and all reporters of error are encouraged and responded to.

How could healthcare teams and individuals be expected to maintain zero error rate if they have no idea what ‘right’ looks like? The vast majority of Trusts and Hospitals have not trained their teams at all in a meaningful way. This is abundantly clear when we go into operating theatres and wards.

Only last week I heard of a theatre sister who proudly announced that she ticked all the boxes and signed the WHO Safer Surgery Checklist so that “all the paperwork was correct at the start”!  It simply cannot be her fault – she clearly has no idea what the checklist is for and how to use it. I bet the local internal audit shows 100% compliance though, so that’s all right then.

A year ago we worked in a small DGH that had 100% compliance with theatre checklist. Not a single anaesthetic preparation room had a ‘Sign In’ sheet in it; the ‘Time Out’ was laminated and on the wall of every theatre – but never used; not one of the Consultant Surgeons had heard of ‘Time Out’ because they always left early for ‘The Boy’ to close up and nobody else ever bothered to use it.

How prevalent is this? Probably highly so. If you work in a department which does perform checks properly be pleased and spread the word.

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Mental Health 2013 Conference

Atrainability is the Main sponsor for Mental Health 2013 Manchester March 14 http://www.publicserviceevents.co.uk/241/mental-health. 
We get 15 minutes in the plenary session and a MasterClass in Human Factors to boot. With our current work to bring HF practical tools to all aspects of healthcare this is crucial to spread the word. 
Today I had a great reception from 70 odd psychiatrists in South Yorkshire. I find it amusing to talk practical HF tools like the sterile workspace concept - not allowing interruptions and distractions to increase error opportunities - with a group of psychiatrists. But it seems we do have a different way of looking at things. The same goes for the basketball video demonstrating our attention weaknesses.
Yesterday with another Mental Health Trust team we discussed using checklists and aide-memoires for such as checking the risk for removing service-users from seclusion. It seems there can be a distinct aversion on the part of the staff to get service users back into the normal part of the unit and the perception of risk is what weighs heavily on their minds. I heard one tale of a patient who was threatening to shoot staff so they wouldn't let him out. But someone pointed out that they were under obs in a seclusion room and couldn't possibly have a weapon!
But under observation for prolonged periods is itself a non-human-friendly task. We teach that the attention span is limited, possibly as little as 20 minutes for concentration. So is it any wonder that lengthy obs are not carried out well? Would it be better to rotate staff around jobs to break up the monotony and keep eyes sharp?
Another issue is being prepared for what could go wrong. I heard of a staff member getting thumped because he was observing a patient taking the air after a violent episode. But the staff member was standing with hands in pockets leaning against a doorway with no room to duck when the patient walked past him and just simply hit him. The two staff had been chatting to each other and had taken eyes off the task. Probably won't do that again, but somebody else might. That is why debriefing to learn is so important.
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What stops experienced medical staff caring?

Following on from my previous post on the Francis report...
 
What are the key elements of the Francis report? Care and compassion of course but what stops experienced medical staff caring? Demotivated, dis-empowered and feeling unloved by their own senior management perhaps? In failing healthcare establishments the staff on the shop floor are not listened to and they are anything but encouraged to report unsafe practice and dangerous practice.
 
When aberrant behaviour goes unsanctioned and is effectively tolerated the effect permeates the whole culture. It becomes one of not caring about poor performance, non-adherence to safe working practice  and inappropriate behaviour. It is corrosive and standards slip away. 
 
Today I have been to a private hospital where the long arm of the CQC has recently been felt. The  bosses are worried about potential legal action, but that is hardly the point. Care for patients who place their trust in healthcare professionals is what it is all about not the legal threat. It should be accepted that best possible safe care practice is the only way. What could possibly be argued against?
 
So I hear of senior clinicians who adopt slack practice that they admit would not be accepted in their NHS Trust. They shout, rant, rage, act like children if not allowed to run 'their' operative list in their preferred order without argument. They also act, dare I say it, like tenage lads - egging each other on to see how far they can stretch things. Actually I experience this in NHS hospitals as well, from people who preach professionalism but don't walk the talk and furthermore have no intention of doing so.
 
What is so utterly amazing is that they think that no-one in their teams notices.  Yet as an outsider when I visit everyone knows who the awkward so-and-so's are. Guys - it is no secret, everyone knows who you are. It is not too late to change, just try asking the people you work with for some honest feedback. 
 
Here is how to do it, referring ideally to behaviour not technical performance:
 
  • Tell me one thing I do well 
  • Tell me one thing I should do more of
  • Tell me one thing I should do less of 
 
If the only answers you get back are technical and not non-technical, perhaps this might be a message. 
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