A systems thinking approach to error
It was evident from the conference that systems thinking is the way forward and the overriding theme of the day was about looking at the bigger picture whilst ensuring we don't lose sight of the individual in the process, especially the patient. We lose sight of the individual at our peril, but more than that, the patient's peril.
When organisations want to identify specific areas to improve or show evidence that they have indeed achieved improvements, data is crucial. But data so often can mask the fact that we are of course dealing with real people.
Whilst 'live tweeting' at the conference about this very subject, a fellow tweeter commented:
And how very true that is; you need both the data combined with the human story to understand why change is needed, why something has gone wrong or particularly well and also to convince others to become advocates, sharing the learning and helping to implement what is required.
We completely support the idea of systems thinking. One of the talks that I listened to with interest was focussed on Root Cause Analysis. They talked about one particular study and what they found was the Root Cause often came back as:
"Process Not Followed".
Now, that sounds like an easy answer, but firstly, that doesn't give much to work with. That's almost as bad as pointing your finger at someone and saying, "That person didn't do it right." More details are needed to understand what is going on.
Taking a systems approach to the 'Root Cause' would take into account the bigger picture and begin to investigate WHY it wasn't followed.
Is it a training issue for the individual?
Is there something wrong with the process which means it's very difficult for front line teams to do their job and adhere to the process?
Or, could it be the person is in the wrong job?
Perhaps it's 'the process' and not the person that is the real Root Cause and it needs revisiting.
It certainly seems to be the case with a number of Surgical Safety Checklists, where it looks like the checklist itself is not fit for purpose.
We are currently working with an NHS Trust where the checklist is not fit for purpose. Investigating, observing and promoting open conversations with front line individuals is a good start for any organisation that wants to understand what they can do to make improvements.
Overall there was a strong feeling of optimism at the Clinical Human Factors Group Seminar. There are, without a doubt, more people taking an interest in Human Factors in healthcare and there is also some truly excellent and insightful work on developing solutions to changing the Culture on this…even if, at the same time, it's apparent there are still some pockets of resistance.