Nick White: Culture of fear toxic to patient safety

The patient safety movement in the UK is ever expanding, following the well- publicised failings at Mid Staffordshire NHS Foundation Trust.

The announcement by the General Medical Council is part of this movement. The GMC, like the Nursing and Midwifery Council, is there to protect the interests of the patients and for this can only be applauded.

When errors occur, families need an apology. They should not expect their healthcare organisations to adopt a code of silence. There should be transparency and action to learn from the event so it’s not repeated. However, it is worth exploring whether these proposals, even though they have the best of intentions, might actually have the opposite effect.

The news coverage has tended to zero in on the word “sanctions” for doctors who make mistakes. Unfortunately, it is well accepted within patient safety science that sanctions don’t increase safety, but actually lower it. Doctors are human beings and they make errors, especially when hospital systems – their policies, procedures and guidelines – set them up to do so.

Professor James Reason, one of the world’s leading experts on industrial safety, suggests that because doctors are fallible, it is the responsibility of hospital managers to ensure that those mistakes are anticipated, planned for and learned from. The GMC has said it wants to impose sanctions where doctors make serious clinical errors. Sanctions are defined as “a threatened penalty for disobeying a law or rule”. Unfortunately, the fear of sanctions and retribution will not stop doctors making errors.

The GMC also talks of a duty of candour and while this can again be applauded – of course doctors should report other doctors who are unsafe – the GMC again suggests “imposing more serious action in cases where doctors fail to raise concerns about a colleague’s fitness to practise”.

Such a culture of fear won’t help the patient safety movement, but actually hold it back. In his recent report to the Government, Don Berwick, a leading patient safety expert, argued that fear is toxic to patient safety and the process of making any required improvements.

We must instead follow the example of other high-risk safety-critical industries, like aviation, nuclear power and petro-chemical businesses. They embrace errors as learning events. These industries investigate thoroughly, are extremely transparent, and they learn and share. They accept human fallibility and design their policies, procedures, guidelines, working environments and equipment around such frailties. Error is often predictable and can certainly be learned from.

Rather than bringing errors to the surface, sanctions may merely push them underground. It may serve to increase cases of cover up and reduce the number of incidents that are reported, when in actual fact there is a recognised drive to increase the number of incidents reported, no matter how small, so that we can learn and prevent similar errors causing harm in the future.

Understanding the human factors at work in high-risk industries has been key to reducing the effects of any errors that are made. Among other things it covers areas such as teamwork, hierarchy, communication, decision-making and workplace and equipment design – as all of these things can have an effect on human performance and error.

Everyone make mistakes, no matter how good they are, so there need to be systems created within healthcare to cope with this fact. We cannot just accept that errors occur and then sanction people, we need to build systems to catch mistakes before they cause harm.

Part of this is about redefining accountability. We should not mix up the word accountability with culpability. We need a healthcare system that does not adopt a blame culture, but a learning culture. To be a learning culture we cannot apportion blame for errors. We need to start accepting that errors aren’t caused by bad people, but by bad systems and that the majority of doctors come to work to a good job for their patients.

Sanctions won’t fix this issue, only learning from mistakes to avoid repeating them in the future will do this.

• Nick White is a senior lecturer in adult nursing at Sheffield Hallam University and an expert in patient safety.