Atrainability Blog

Here we share some thoughts, insights and ideas related to Human Factors Training

Honesty is the best policy?

Trending today in the news is the story of a transplant gone wrong.

The Oxford University NHS Foundation Trust agreed £215,000 of damage for one of the resulting cases, where a 36-year-old patient died of an aneurysm caused directly by infection from a donated liver.

Two other patients who received transplanted organs from the same donor also became ill.

The story relates to an incident in 2015, where the surgeon harvested several organs, but nicked the stomach during the retrieval process, spilling contents over the other organs, resulting in infection.

As much as we don't like to speculate, we have to question what was happening in the mind of the clinician who must have been aware they had perforated the stomach.

There is serious learning from this incident, for all involved. We must now ask how the experience can be best disseminated, in an effort for this to never happen again.

What I would hope to see from the surgeon involved is humility. One assumes they would be embarrassed and, in the spur of the moment, elected not to report the incident. Which of us hasn't made a comment or decision in a single moment, we haven't subsequently regretted?

One would hope that a professional, in whatever field, would be able to swallow their pride, overcome their embarrassment, and do the right thing, for the right reasons; the essence of professionalism.

We can't afford everyone to go through learning by trial and error. People often throw out the line, "lessons should be learned", but let's consider first what those lessons should be.

There's an opportunity for someone who has been through this experience to share their learning with colleagues, turning a severe negative into a positive.

I know from my time as a training captain in aviation that, to make a mistake as an expert, we must share that experience with others. We are held to a higher standard.

Where mistakes happen as a professional, you must swallow your pride. You must try to find a positive out of what is a devastating incident.

I can understand why the patients and their families would seek to apportion blame in an incident like this. But I would hope that the event was unintentional, and failure to admit their mistake (and be honest) at the time, a failure they have subsequently lived to regret.

What would striking off a clinician achieve? As long as they accepted their role in the mistake, that is. Assuming this is the case, they possibly become the best person to teach others.

If they demonstrate reflective learning and the appropriate attitude, and of course the duty of candour, with support from colleagues and management share what they have been through, hopefully that could produce some benefit for others in a tragic situation.

We do, however, meet people who won't accept their part in such incidents. These people are a real worry. When the attitude is, "well, it's just one of those things!", that approach isn't good enough.

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Near hits and the tip of the iceberg

When things go wrong in healthcare - administering the wrong drug, treating the wrong patient, operating on the wrong site or patient - these are the mistakes we see. Sadly, avoidable harm is not decreasing and the annualised cost increasing in our litigious society. £2 billion outgoings for NHS Resolution in 2018, up from £1.7 billion the previous year.

What people often don't do is report the near misses, or near hits as we prefer to call them.

There's plenty of understandable reasons for not reporting the near hits.

Firstly, nothing has actually gone wrong. It's hard to report a near hit when it didn't result in a bad outcome for the patient.

Secondly, reporting systems tend to be very cumbersome and time-consuming; not something you would look forward to at the end of a long shift.

The boxes within these reporting systems don't always fit the scenario. When no actual harm has taken place, some of the older systems don't have a way to report the near hit from their drop-down boxes.

Another major reason healthcare professionals fail to report the near hits is because nothing tends to happen when the issue is raised. All too often, there's no reply to acknowledge the report or even say thank you.

If there is an acknowledgement, frequently nothing is seen to change. From a management point of view this can be frustrating because not all solutions can be visible. We know of a case of senior management following due process with a case of bullying but they can't publish that they put a warning on a personal file because naturally that is confidential. But staff see no change in behaviour of the culprit so don't waste time offering follow-up reports!

One more reason; when you report near hits, you don't always feel safe.

We are aware of one situation, involving a clinician working with a new colleague. They were chatting together, slightly distracted, and the new team member got the controlled drugs out in a different way.

The clinician knows they should have checked before administering the drugs, but they were distracted. They gave the wrong one of the two colourless solutions to the patient. Fortunately, there was no lasting harm to the patient, but this was a near hit.

The clinician decided to report the near hit. They were aware that the same had happened with some of their colleagues in the past. Human factors were involved, with a weakness in the drug-labelling system making the error easier to occur.

The result? After reporting the near hit, the clinician came under scrutiny from senior management. They were not thanked for raising the near hit. Instead, the management started looking into how many near hits the clinician had previously reported, comparing their frequency of reporting to management.

The irony in this is, they made the clinician who reported the near hit feel victimised. Yet management still went ahead and changed the process, to reduce the risk of the same near hit retaking place. Dishonest management in our opinion.

When I was flying jumbo jets with my former employer, there was a company policy of error reporting ethics. If you made a genuine human error and confessed it, you would not suffer any disciplinary action or consequence to your career.

If however you deliberately broke the rules or made an error then tried to hide it, you would be facing due process. And quite rightly too.

Airlines too, recognise the tip of the iceberg issue. If a near hit is reported, it's likely to be part of a much bigger problem, hiding below the surface.

The more comfortable thing for management to do is to discipline the last person involved; the nurse, doctor or pilot receives punitive action as a result.

The hard thing to do is to get to the true root cause of the issue.

Why did the person make the mistake that resulted in a near hit? Perhaps they were not adequately trained in the procedure. Indeed the process itself could be unfit for purpose. The staff member might have been working for many hours without a break. They could have been experiencing personal issues at home, with a sick or dying relative, distracting them from the task at hand. We know of one recent case where this was a major factor.

In the long term, it saves you money to take the hard option and tackle the system issue which may be indicated by the hidden mass of the iceberg, floating below the surface.

So please report near-misses or as we say regard them as near-hits. The message for managers is please encourage reporting and respond with compassion for the reporter. The bulk of the iceberg represents a threat to us all.

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