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Focus on just culture, not individual blame, will improve patient safety

A culture of unfairly criminalising doctors when things go wrong makes it harder to improve patient safety

Louise Prime

Monday, 16 September 2019

We need to focus on creating a “just and learning culture” so that we can learn from health professionals’ mistakes and improve patient safety, the Medical Defence Union (MDU) warned this morning. It argued that the current system – of unfairly singling out doctors whose actions have led to patient harm – is “almost set up to fail” because we lose the opportunity to learn what cultural and systemic changes might have prevented the incident.

The MDU has examined what it calls the fundamental importance of getting organisational culture right – switching the focus from blaming an individual, to working out why that person, within the system, was not able to deliver the safest care possible. It pointed out in a report last week that, for example, deaths from the intrathecal administration of vincristine kept on occurring even though as early as 1978 the report into the death of a child in the US had recommended solutions, including the need to clearly label syringes and not place intrathecal and intravenous drugs in the same treatment area. It said: “The NHS was not learning from these fatal errors and prosecuting those medical practitioners involved was not the solution.”

The MDU said the history of intrathecal vincristine deaths “exemplifies the tension that arose between a perceived need to find fault and blame, and the need to learn from the tragedy that occurred” – by examining, for example, systemic failings including inadequate clinical supervision, absence of a data sheet for the cytotoxic drugs and very inexperienced junior doctors and student nurses being involved in the process contributed to the catastrophic outcome.

MDU head of professional standards Dr Michael Devlin called this morning for lessons to be learned from mistakes of the past. He explained: “In order to move forward with improving patient safety, it’s important to acknowledge that the punitive systems of old have not served patients and their families well. However, a fresh approach, built on a just culture, will.

“The current system is almost set up to fail; a patient’s unexpected and preventable death may lead to a criminal investigation, a coronial investigation, disciplinary and regulatory procedures, civil litigation and media coverage. Sometimes these processes are necessary, but where the focus almost immediately narrows to an individual’s failings, what is often lost is the opportunity to properly and rigorously examine the context and the wider systems failures that are often at the heart of such incidents. …

“For decades, doctors were criminalised for their part in fatal drug administration errors, but this did not help. What was ultimately needed was to understand the human and systemic factors that influenced their behaviours.”

He added: “We know that the move to a just and learning culture will not happen overnight. It will require knowledgeable and motivated clinical leaders and managers, and time to restore trust and confidence in processes designed to investigate clinical errors. However there is already some useful guidance out there which leaders can turn to such as NHS Resolution’s report Being Fair and NHS Improvement’s Just culture guide.”

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