How do we begin to address our individual responsibilities? How can each of us reduce the personal risks we pose for our patients? How do we begin to address the moral imperative to recognise and then overcome any professional complacency that may interfere with our performance? 

Dan believes by enhancing human performance within healthcare settings this will serve as the ultimate key to improving quality and safety. Recognition by clinicians of their own tendencies toward complacency and their own vulnerabilities toward making mistakes is to encompass a mandate for personal professional commitment and improvement.  

If patients are harmed on the frontlines in healthcare settings, then it is on the frontlines that many of the solutions can be found and safety improvements nurtured. First recognising, and then modulating, the human factors liabilities that exist on the frontlines and overcoming the challenges of professional complacency will be necessary steppingstones towards sustained improvements in providing patient safe care.  

Clinicians, managers and leaders need to work collaboratively to understand and overcome the challenges that human factors pose when addressing individual performance.

Further reading on the hub from Dan:

• Clarity and the Art of Communication for Patient Safety
• Late night reflections on patient safety: commentaries from the frontline (2014)
• Patient safe care as a moral imperative: The mandate of medical ethics
• Diagnostic errors and delays: why quality investigations are key
• Patient Safety Spotlight Interview with Dr Dan Cohen, Patient Safety Learning Trustee
• What does all this safety stuff have to do with me? How one professional’s arrogance led to new insights
• Interview with Dr Dan Cohen on human performance

The ten topics are:

• organisational safety culture
• managers’ leadership
• communication
• team (structures and processes)
• team leadership (supervisors)
• situation awareness
• decision making
• stress
• Fatigue
• work environment.

Hmmm…, a damaged and lost soul!

My first reaction was to wonder what kind of slimy rock this chap had crawled out from under. However, rather than get annoyed, an emotion that rarely results in improved communication, I simply mentioned that the most current analysis of injuries resulting from patient safety incidents has revealed that the majority of serious injuries, malpractice claims and settlements result from errors or delays in diagnosis and that, the last time I checked, clinical diagnosis is primarily the purview of doctors not nurses. I figured he might want to continue the conversation, but he simply turned and walked away. The truth hurts and I was left wondering how many patients he had harmed, knowingly or unknowingly, during his career. Blaming others can be an easy out from self-examination. 

As I thought about this interaction later that evening, putting his insulting arrogance aside, it occurred to me that his complacency about his role as a contributor to the patient safety conundrum, and the challenges of assuring diagnostic accuracy specifically, is probably much more common than many would like to admit. Fortunately, his degree of professional arrogance is generally not the rule among compassionate professionals. Still, there is something to learn from his arrogance and from what he said.

Complacency, subtle, unrecognised and perhaps pernicious, can become a malignant force. We are all prone to this. We all know that caring for patients, especially for vulnerable patients, is fraught with hazards. We work in highly complex environments, interacting with innumerable patients and professionals every day, each of whom brings strengths and liabilities into the equation we call healthcare. We all acknowledge that there are deficiencies in the structures and processes of healthcare systems and these numerous deficiencies can contribute to patient harm. Anyone who has spent time working in healthcare settings can point to examples of poor leadership, unsafe and unjust cultures, demand-based management and flawed or inadequate healthcare processes that may adversely affect the provision of care and can degrade professional morale. We have all been there.

Well-documented deficiencies in the structures and processes of healthcare certainly encumber those working to actually provide care.  Frontline staff working under pressure can and will make mistakes; even in institutions where robust efforts have been made to support staff and specifically improve the working environment on the frontlines, mistakes will still occur.  Human beings make mistakes, and even though our processes can be standardised to reduce variability and enhance ease of performance, mistakes still will occur, especially in the domain of diagnostic accuracy where standardisation is not so robust and cognitive insufficiencies and biases abound. Caring for patients is complicated stuff!

Healthcare professionals do not get up in the morning intending to harm anyone, but normal human liabilities can impair our performance.  Often we do not even recognise our own liabilities or are unaware of the environmental factors that can enhance them. Workplace complexities and associated stressors such as fatigue, hunger, patient volume and acuity complexity can all contribute to distractions in an already task-saturated environment. If we also factor in outside family, social and economic pressures of various kinds, which we rarely leave at home entirely, the stage is often set for mistakes to occur, sometimes very serious mistakes.  

The aviation industry is an example of a highly reliable industry where safety is paramount and is often held up as a standard of performance to strive for in healthcare. But an A&E unit is a much more complex and relatively uncontrolled environment than the flight deck of an Airbus 320. In my view, the aviation metaphor commonly falls short when compared to healthcare.  As a physician who has also worked in the aviation community for part of my career, I feel that although important lessons can be learned and shared from the aviation industry, the aviation environment is not a mirror image of the healthcare environment.  

Anyone out there ever made a mistake when caring for a patient? I have made many, I suspect, most unknown to me and of little or no consequence to my patients. I did make a more serious mistake once and my patient, a 9-month-old child, was dangerously but not permanently harmed.  

When oncologists make mistakes, the consequences can be catastrophic as chemotherapy agents are dangerous. The truth is, I was complacent and didn’t see the potential for harm coming right at me; my fault – or at least that was how I viewed things. I became a ‘second’ victim as a result of this incident and it still resonates with me, all these years later.

Hospitals with strong committed leadership are attempting to address the challenges that those on the frontlines must face every day, especially in settings such as A&E units, but one cannot simply design out all of the confounders. There are some excellent examples of robust, patient and staff-focused leadership, safe and just cultures and collaborative management, and these should be emulated nationwide.

This all brings me back to the arrogant doctor who wanted to blame the nurses for “all this patient safety stuff”, and his inherent failure to recognise his own singular, important role in the patient safety conundrum. I suspect that this is a natural tendency, as healthcare professionals do not ordinarily see themselves as sources of harm, a concept that is counterintuitive to who we think we are and the excellence in care we strive to provide.

The fact is that we may all suffer from some degree of professional complacency. We may often fail to recognise environmental and situational risks, and, more importantly, to admit to our own personal liabilities, and, thus, the risks we bring into the healthcare environment. Though we all recognise how complex the provision of healthcare can be, we may not fully appreciate that we are also part of that complexity. Our inability to recognise the often subtle but inherent risks we bring to our patients in all healthcare settings is surely an independent variable in the calculus of providing patient safe care. 

So, I propose the following for all healthcare professionals – each day, before we enter our hospital or surgery, care home or whatever, please pause and repeat the following mantra:

“I am a kind and caring professional about to enter a complex healthcare environment where patients may be harmed every day. I admit to myself that although I always intend to serve my patients as best I can, I also inherently represent a source of risk for them and I may make mistakes that can result in harm. Though I may wish to deflect responsibility onto insufficiencies in structures, processes, leadership, culture, managers and even other colleagues, the fact is that I am also a unique risk to my patients. I will be very careful, every day, in every way, with every patient under my care, all the time; and I will strive to be even better tomorrow.”

Read Dan's full length article: Structures, processes and outcomes for better or worse: Personal responsibility in patient safe care

Further reading on the hub from Dan:

• Clarity and the Art of Communication for Patient Safety
• Late night reflections on patient safety: commentaries from the frontline (2014)
• Patient safe care as a moral imperative: The mandate of medical ethics
• Diagnostic errors and delays: why quality investigations are key
• Patient Safety Spotlight Interview with Dr Dan Cohen, Patient Safety Learning Trustee
• Interview with Dr Dan Cohen on human performance

• What are they? 
• What are their role in healthcare?
• What are the different factors that affect my performance in practice?

• Martin Bromiley talking a little about his story and the impact of design, followed by discussion with Francois Jaulin and Frederic Martin from the Anaesthesia Network.
• Dr Tom Clutton-Brock, Clinical Director of Trauma Management, discussing regulations in design safety and usability.
• Tracey Herlihey, Head of Safety Intelligence, HSIB, looks at the consequences of bad design.
• Colette Longstaffe, Product Assurance Specialist, Clinical and Product Assurance, NHS Supply Chain, looks at what the NHS is doing differently in procurement.
• Panel discussion with Martin Bromiley, Colette Longstaffe and Tracey Herlihey joined by Rob Turpin from the BSI and chaired by John Pickles, CHFG Chair. 
• Dan Jenkins, Head of Research (Human Factors and Interaction), DCA Design International, looks at how we can use Human Factors to design better medical devices.
• Professor Chris Frerk, Anaesthetist, gives real life examples of the impact of poor design.
• Richard Featherstone, Director of Human Factors Research & Design at Emergo by UL, talks about medical devices and user errors. 
• Panel discussion by Professor Chris Frerk and Dan Jenkins plus Duncan McPherson from the MHRA, Chaired by Professor Rhona Flin, CHFG Trustee.

• Why human factors are important.
• How human factors are embedded into NHS work.

1. People aren't machines
2. Push the button
3. Differeing shapes and sizes
4. Stamina and repetition
5. Look around