As I'm writing this, it's only Wednesday, but we have already been made aware of four unrelated never-events at seperate healthcare providers. The unfortunate truth about committing to a Human Factors training programme is that many organisations put it off, until they receive a wake-up call in the form of a never-event, a near miss, bad press or from the CQC. Someone gets told this needs to be addressed, and that's when our phone starts ringing.
The first tragedy of so many harm related incidents is that on reflection they could have been avoided.
That's one of the reasons this headline in the National Health Executive: "NHS pays out record £20m compensation for brain-injured teenager" caught our attention, but also because it's potentially the largest compensation pay-out in NHS history.
The second tragedy of avoidable harm is that the suffering of all those involved doesn't end with the error.
The judgement suggests the error was avoidable. Hence Human Factors behaviours will likely have been suboptimal. In this particular case, not only did this nameless young lady have her full enjoyment of life tragically taken from her, but also her parents and entire family.
We can only imagine the emotional toll that they have endured for the last eighteen years to have this life changing error acknowledged and receive some form of compensation towards her ongoing care.
Let's also recognise the effect on the healthcare team involved. It's likely that disciplinary action would have been taken, but they have almost certainly been haunted by the knowledge that they could have avoided or trapped the error.
The third tragedy of avoidable harm, is that it sadly continues to occur.
There will always be mistakes in healthcare, but embracing a Human Factors mindset can enable your team to be confident in modifying the actions and behaviours that affect safety.
Atrainability have over 16 years' experience in training and supporting healthcare teams on their individual journeys to truly learn, become more effective and begin to change behaviours for the better. If your teams are performing highly now, consider helping them to stay 'consciously competent' and avoid the trap of complacency.