Patient Safety Spotlight Interview with Dr Dan Cohen, Patient Safety Learning Trustee

Summary

This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Dan talks to us about how his experiences as a paediatrician and military doctor have influenced his view of patient safety. He also describes the increasing complexity in healthcare systems and highlights the need for the Government to commit policy and resources to building and sustaining the NHS workforce.

About the Author

Dr Dan Cohen is a former US Department of Defense (DoD) physician executive with career culminating as Chief Medical Officer and Executive Medical Director for the DoD TRICARE health plan, which currently provides health care to over nine million beneficiaries worldwide. Most recently, Dan served as Chief Medical Officer for Datix where he championed the company’s comprehensive patient safety thought leader efforts internationally through conference presentations, publications and commentaries.

Questions & Answers

Hi Dan. Please can you tell us who you are and what you do?

I’m Dan Cohen, a retired American-trained paediatrician, haematologist/oncologist and career military officer, having served in the US Air Force for nearly 30 years. 

During my military career I lived in the UK for 14 years as part of the American NATO contingent, at which time I became very familiar with the NHS. Later in my career, I became Chief Medical Officer of the US Department of Defence Health Plan which covered, at that time, about 8.5 million people; that’s about the same size as NHS Scotland and NHS Wales combined! The organisation provides healthcare for service members, their family members, retirees and their spouses, and consisted of about 85 hospitals and hundreds of outpatient clinics, in addition to healthcare services in a network of commercial providers. My role included overseeing and improving the safety and quality of care. I started the position in 2000, the same year the Institute of Medicine published the report ‘To Err is Human’, which many people see as a seminal moment in the patient safety movement.

So, I have had extensive work experience on both sides of the Atlantic. My wife and I currently live in Suffolk, near Bury St. Edmunds, for up to six months each year. Our primary residence is in Virginia. We love England very, very much.

Following my retirement from the US military, I did some international healthcare consultancy and ended up working as Chief Medical Officer for the UK-based patient safety software company Datix (now called RLDatix) for eight years. When Patient Safety Learning was set up, I was invited to become a trustee. Hopefully I bring an international perspective to the table and am very glad to be contributing to Patient Safety Learning’s future.

How did you first become interested in patient safety?

Early in my career as a haematology/oncology doctor at the Boston Children’s Hospital, I was involved in an incident where a child almost died as a result of a medication error. It was a typical systems problem, where multiple things went wrong and the holes in Professor James Reason’s Swiss cheese model aligned. A doctor injected the child with ten times the dose they should have received (both a pharmacy and bedside administration error) and I didn’t find out about this until several hours later on my ward round, when I saw the used syringe and realised the error. Although I wasn’t the individual that administered the medication, the child was my patient, so I felt responsible. Fortunately, the patient survived, but I struggled for a long time with what had happened. I had a long conversation with the child’s parents about what had gone wrong the morning after the error was discovered, and they welcomed my candour and forgave me. Eventually I learned to forgive myself too. 

If there’s anything in my whole career that changed my perspective on patient safety, it was this incident. It made me realise how vulnerable patients are, how vulnerable the people working on the front lines of healthcare are, and how easy it is to make a mistake, even in the best systems.

What did you learn about system safety from your time in the US military?

While in the US military, I was involved in aviation medicine for six years. I did a lot of flying and became familiar with the challenges the air crew faces in a unique and hostile environment. I learned a lot from that, but it is overly simplistic when people suggest we should just use the aviation industry safety model in healthcare. That view is a bit off-target, as the environment that aviation takes place in is very different from healthcare settings. 

High reliability organisations are those that have mechanisms in place to continually focus on the likelihood of errors occurring and to make corrections. The most important people in the high reliability model are the people working on the front lines. In aviation, that's one or two individuals controlling the aircraft and several individuals on the ground providing air and ground control support. All of these individuals are supported by a range of passive and active technology which is constantly feeding them information from computers to provide a clear picture of the situation and evolving risks.

In healthcare, however, the people on the front line are healthcare professionals and the patients. Patients have had no training in high reliability, and there are so many nurses, doctors and other healthcare professionals working in a healthcare setting that it is impossible to have the same level of control. The only area of a hospital that could be compared to the flightdeck of an Airbus 320 is the operating theatre. Once you get on to the ward or into outpatient settings, things get complicated, really quickly.

How has your view of patient safety evolved throughout your career?

Early in the patient safety movement, we focused on what I see as the low-lying fruit such as reducing healthcare associated infections (HAIs) and medication errors. It was about understanding, identifying and dealing with points of weakness in the system, and in many instances we were successful. Now, we’re dealing with very different issues that can’t be fixed using the same methods, such as a stressed and depleted workforce. A pressing issue in the UK is lack of funding to provide decent salaries for healthcare professionals, nurses and support staff especially, and to refurbish and build new hospitals. 

On top of that, some of the previous challenges we thought we had dealt with have come back to haunt us because of the impact of the Covid-19 pandemic. So, the patient safety issues now are, in some ways, more structurally complex and harder to find ‘quick fixes’ for. Investment in what I call ‘Human Treasure’, is essential, or the NHS will fail. 

While you were working as a doctor, which element of your role did you find the most fulfilling?

For me, the answer to that is very simple—the most fulfilling part was always working with people on the front line and paying attention to them. Listening to patients is a skill that we simply assume healthcare professionals are good at, but the fact is that many of us are not good listeners. Listening to the day-to-day problems that patients and staff are facing is so important. That means really taking on what patients and staff are saying as well as simply hearing their words. To paraphrase Sherlock Holmes, “we may see, but we don’t observe”!

What patient safety challenges do you see at the moment?

The NHS system of care is vastly different to US healthcare, and the two systems have differing and distinct challenges. In the UK, resources, staffing and funding for the NHS are deficient in many areas, and the needs of the patients are increasing as the population ages. In the US, over-utilisation of the health system is a major problem—there are too many tests and too many procedures of questionable value. The US ‘fee for service’ healthcare system can lead to increases in utilisation—it drives income but also increases opportunities for errors. 

A few years ago, I was on a ward round in southern England with a consultant friend and I was amazed at the complexity of the physical environment in his NHS hospital. I also witnessed many communication challenges, including during shift handovers and between staff and patients. It made me realise that the NHS has so many great staff who are committed to helping people get better, but the environment they are in is set up to hinder them from doing a good job. It’s like we need to go back to the beginning and redesign how it all works, and my friend was attempting to do just that, thank goodness!

During the Covid-19 pandemic, staff were literally overwhelmed and couldn’t offer the quality of care they would want to. Take, for example, a procedure such as inserting an indwelling catheter into a blood vessel. We know from research that if you treat the insertion of a vascular catheter as a surgical procedure, with appropriate cleansing, gowning and other care precautions, and take the catheter out as soon as it’s no longer needed, you can prevent nearly all indwelling catheter infections. But when staff are overwhelmed and exhausted, these standards can’t be maintained—since the start of the pandemic, data shows a steady increase in the number of indwelling catheter infections, and these can be fatal.

The other issue I see as a priority for the NHS is addressing the nursing staff shortages, as the extensive hiring of agency nurses is a patient safety issue. A ward sister in a UK hospital recently said to me, “Dan, I don’t even know who’s coming to work tomorrow.” Agency staff may not know the layout of a hospital or the processes and procedures in use in that department, and if staff don’t know each other, that’s an immediate barrier to effective communication and safe care. The NHS also needs to be investing in the nursing leaders of the future by giving them opportunities to progress and paying them a wage that values them. Salaries for nurses are insufficient for stable recruitment and sustainable career advancement. The same can be said for other healthcare professionals, and the NHS needs many more doctors, both GPs and consultants, in my view. Many healthcare professionals are coming to retirement age and the NHS really needs good future leaders.

It troubles me that people in Government don’t seem to be listening to people from within the healthcare system, especially those on the front lines, and that is the essential requirement for achieving higher reliability and better outcomes. It’s the outside forces that have huge influence on health systems that need to change their approach and work together with frontline staff to face up to the challenges. I would also point out that the other, most important, people on the front lines of the NHS are the patients, and they know full well what is working and what is not. Government leadership needs to listen to these ‘frontline’ folks also.

What do you think the next few years hold for patient safety?

The NHS is a wonderful concept, but I don’t think the current system is what Aneurin Bevan envisioned. To improve patient safety in the next few years, the NHS must address the issue of access to care. I have a friend in my village who needs a hip replacement and has been told that a 12-month waiting time is an optimistic time frame for having the procedure. I view every day that he is living with pain and functional disability as a patient safety incident. The only way to correct that is to provide sufficient resources to support the goals of the NHS—that means providing sufficient resources across the board, paying healthcare professionals fairly and investing in training more staff to meet expanding needs. Patients were promised prompt access to care seven decades ago, and that promise seems to no longer be the driving force, or preeminent in the thinking of leaders.

If you could change one thing in the healthcare system right now to improve patient safety, what would it be?

The NHS needs some very strong leadership to overcome the issues it faces—it’s clear the British public really values it and wants it to succeed. I’m cautiously hopeful about the opportunities for improvement in the healthcare system, if they can be embraced. There’s not one solution, but I want to see the NHS taking the opportunity to innovate. I believe the structure of the NHS makes it an ideal platform for innovation. A joined-up approach to testing new strategies in different areas of the country would allow the NHS to compare systems and implement best practices more widely. At the end of the day, however, it is the Government that needs to view the current situation as an existential threat to the health of the nation and to act accordingly.

Patient Safety Learning can be part of the effort for sustained improvement in healthcare safety, and I think the Patient Safety Standards we’re developing will help us to determine the effectiveness of different interventions and collaborations. They might well be a foundational piece of the jigsaw for improving the safety of healthcare, resulting in truly patient-safe care in the UK.

Can you tell us something about yourself that might surprise us?

Although I might come across as a sceptic, I’m actually a perpetual optimist and have tremendous confidence in the ability of human beings to make really meaningful contributions. I’m hopeful that with the right buy-in and methods, we will be able to improve the state of the UK’s beloved NHS and return it to its rightful world-class status.

Related reading

What does all this safety stuff have to do with me? How one professional’s arrogance led to new insights