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.