Sue Osborn: How do we stop errors?
From a speech by the joint chief executive of the National Patient Safety Agency to the British Medical Association conference, London
Your support helps us to tell the story
From reproductive rights to climate change to Big Tech, The Independent is on the ground when the story is developing. Whether it's investigating the financials of Elon Musk's pro-Trump PAC or producing our latest documentary, 'The A Word', which shines a light on the American women fighting for reproductive rights, we know how important it is to parse out the facts from the messaging.
At such a critical moment in US history, we need reporters on the ground. Your donation allows us to keep sending journalists to speak to both sides of the story.
The Independent is trusted by Americans across the entire political spectrum. And unlike many other quality news outlets, we choose not to lock Americans out of our reporting and analysis with paywalls. We believe quality journalism should be available to everyone, paid for by those who can afford it.
Your support makes all the difference.As in many areas of life there is risk in health care, NHS staff are human beings and will make mistakes. We therefore need to create systems that lessen the likelihood of mistakes happening and ensure that when mistakes do happen, the whole NHS is able to hear about and learn from them – to reduce the risk of them happening again.
The National Patient Safety Agency is required to develop and manage a national system for all NHS organisations for recording, analysing and learning from "adverse events" – where unintended harm is caused to patients. We will receive information from NHS Trusts on what has happened when something has gone wrong, rather than the who.
The NPSA will be looking for trends and patterns amongst both adverse events and "near misses" and ask the Trusts involved to look at the root causes of each event so that the learning can be shared with others in the NHS to prevent future occurrences.
A key barrier preventing NHS staff from reporting things that go wrong is a fear of blame. The NPSA is unique in that it is the only organisation in the NHS with the role of promoting and supporting a more open, fair and just culture. The system we run will be anonymous and the success of it will depend to a large extent on the willingness of staff to report events when they occur. This will not happen if there is a punitive culture and there is extensive research from other industries and countries that shows that a more open and blame-free culture leads to a higher quality and safer service and a visible reduction in errors.
We can learn a lot from historical events, such as the sinking of the Titanic where a catalogue of failures and preventable errors led to the sinking of the unsinkable ship. A modern-day response in our existing "blame and train" culture might have been to send a Captain Smith equivalent on a training course on iceberg spotting.
How do we stop the repetition of preventable error? Our response to error is directly related to our organisational culture and an organisation's culture is reflected by what it does – its practices, procedures and processes.
We will be focusing on the achievement of all of these issues – because they will all reduce error and save lives.
Join our commenting forum
Join thought-provoking conversations, follow other Independent readers and see their replies
Comments