Summary
In this blog, hub topic lead Aditi Desai considers whether retrospective inquiries alone are enough to improve maternity safety, arguing that individual errors rarely explain the full picture. Aditi explores how systems thinking and human factors expertise can reveal the pressures, interactions and everyday working practices that create hidden risks across maternity services. She calls for the considerable energy currently devoted to investigating harm to go towards designing safer maternity systems before the next incident occurs.
Content
A systems thinking approach
When serious harm occurs in maternity care, the understandable response is to investigate. Reviews and inquiries do have an important role in establishing what happened, identifying concerns, giving patients and families a voice, and ensuring accountability.
Yet repeated maternity investigations across the NHS also raise a difficult question:
Are retrospective inquiries, on their own, enough to make care safer?
Alongside investigating individual incidents, perhaps we need to devote greater attention to understanding the system in which those incidents occur.
Maternity care is such an extraordinarily complex, often unpredictable, environment. Women may move between community care, triage, labour wards, theatres and postnatal services. Care involves multidisciplinary teams working across shifts, often under considerable workload and time pressure. Decisions are made rapidly, information is handed between professionals, equipment and technology interact with established working practices, and apparently small but safety-critical processes can depend heavily on human memory and vigilance.
Most of the time, this complex system works remarkably well. But when something goes wrong, identifying an individual error rarely explains the whole story.
A systems-thinking approach asks different questions:
How was the work actually being done?
What competing demands were staff managing?
Where were the points of vulnerability and risk?
Were processes dependent on memory or workarounds?
How did staffing, environment, equipment, communication, technology and organisational culture interact?
And importantly,
What made the actions of the people involved seem reasonable at the time?
This is where human factors professionals could make a much greater contribution to maternity safety.
For a maternity service experiencing safety concerns, an independent human factors team could spend meaningful time observing everyday clinical work; not simply examining the circumstances surrounding serious incidents. They could follow pathways across different environments, observe handovers and multidisciplinary working, speak with staff and patients, and examine safety-critical processes.
The purpose would be to understand how the system really works in practice, and where its design may unintentionally create opportunities for error.
There can be an important difference between work as imagined (how a process appears in a guideline or policy) and work as actually done in a busy maternity unit. Staff adapt constantly to workload, interruptions, competing priorities and changing clinical circumstances. Understanding those adaptations can reveal risks that may not be apparent from reviewing an incident in isolation.
This approach need not replace appropriate investigation or accountability. It could run alongside them.
There is a distinction that is important to understand. An inquiry primarily looks backwards: what happened and why? A systems-based evaluation can also look forwards: how does this service really function, where is risk accumulating, what makes safe practice difficult and how could we redesign the system before another patient is harmed?
It may also create a more constructive form of learning. Healthcare professionals may be more willing to describe the realities of their working environment when the purpose is genuinely to understand and improve it rather than simply to identify failure. Staff often know where the vulnerabilities are, the processes that are cumbersome, the tasks that rely too heavily on memory and the workarounds that have gradually become normal practice.
Patients and families could similarly be involved. They experience the pathway differently and can often see fragmentation, communication problems and inconsistencies that may be less visible from within individual clinical teams.
Designing safety rather than simply investigating harm
Other safety-critical industries have long recognised that safety cannot depend solely upon good people trying harder.
Healthcare professionals are human. They become tired, they are interrupted, they work under pressure and occasionally they will make mistakes. A resilient healthcare system should anticipate this reality rather than expect human vigilance to compensate indefinitely for weaknesses in system design.
The aim should, therefore, be to design systems in which the safe actions are easier, more intuitive and more reliable, and in which a single human error is less likely to reach the patient. This is a tall order and will require investment. Safety science arguably states ‘if you think that building safety is expensive, try an accident’.
Sometimes this may involve major organisational change. At other times, relatively simple changes to a process, equipment, communication or technology may reduce cognitive burden or make a safety-critical step more reliable.
Maternity care deserves this level of systems thinking
We will undoubtedly continue to need investigations and inquiries when serious failures occur. Families deserve answers, organisations must be accountable and lessons from harm must be understood.
But perhaps we should invest just as much intellectual energy in understanding what happens between the serious incidents during the thousands of ordinary interactions, decisions and processes that make up maternity care every day. This is where positive workflows can be identified in certain healthcare organisations. Vulnerabilities may develop, but it is also where opportunities to prevent harm can be found.
When a maternity unit is experiencing difficulties, alongside asking “What went wrong?”, perhaps we should bring in people with the right expertise to ask a broader question:
“What is it about this system that makes harm possible and how can we redesign it to make safe care more reliable?”
That could turn some of the considerable energy currently devoted to investigating harm towards something equally important: designing safer maternity systems before the next incident occurs.
Further blogs on the hub from Aditi:
About the author
Aditi Desai is a consultant in maternity and gynaecology at The Royal Wolverhampton NHS Trust. She is the co-founder of iCount, an innovative patient safety solution designed to prevent items from being accidentally retained in the body after childbirth and surgery. Aditi believes that designing sound systems makes it easier for healthcare professionals to do the right thing and deliver care safely.
Aditi graduated in 1995 and has since worked in women’s healthcare, leading numerous NHS improvements. She also tutored postgraduate doctors for several years and has published many research papers. Outside of work, she believes that ‘Music is the Food for the Soul’ and is a member of the NHS Wolverhampton Choir.
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