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Key learning points Education and training of healthcare workers Equip the workforce with the fundamental knowledge and skills of human factors/ergonomics. Support, promote and embed the discipline in the practitioner’s professional training and development. Empower participation in human factor/ergonomic initiatives. Draw on existing expertise. Organisational commitment Comprehensive, resilient, proactive patient safety programme. Safety culture (not punitive to individual). Risk management system. Programme evaluation, meaningful and informative indicators, continuous learning and improvement.

Presentation slides Video of presentation (29:21)

Guidelines and information on: healthcare in prisons in England healthcare for offenders in the community in England healthcare for offenders in Wales Community Sentence Treatment Requirements National Partnership Agreement for Prison Healthcare in England 2018-2021.

In this report the CQC have seen much good and outstanding care, in particular around: responsiveness staff interactions with patients effective treatment leadership and engagement with staff and patients. However, there were a number of areas where services needed to make substantial improvements: governance clinical audit safety culture.

I work in, both, the work imagined and prescribed, but practice in the world of work done. It’s interesting working in both worlds and has made me ask these questions: Why this happens? What are the consequences? How can we manage this disconnect? Real-life scenario What happened? A patient on a ward needs a nasogastric tube (NGT) for feeding and giving medication due to an impaired swallow following head and neck surgery. The nurse prints off the policy for placing an NGT from the Trust's infonet. The nurse inserts the NGT and checks the policy on how to test if it is in the correct position. The tube could be in the stomach (the right place) or it could be placed in the lungs (not a great place for medicines and feed to go!). The nurse calls the nurse in charge for support. It’s been a long time since she has placed an NGT and she wants to check she iss doing the right thing. The senior nurse arrives, before the feed is commenced. The senior nurse notices that the policy that the nurse is using is out of date. Checking the position of NGTs had changed. The senior nurse prints out the updated policy – NGT was in the correct position. This was a near miss event. So what? If an NGT is in the lung and you give medication and liquid feed there is a high chance the patient would contract fatal pneumonia at worst or a protracted stay on the intensive care unit on a ventilator at best. In both these cases, it would need to be declared to the regulators as they are classed as serious incidents. What next? This incident was one of many near misses that were collected over four shifts. This incident was discussed with the Deputy Chief of safety within that Trust. His first reaction was: "When was this? We had a Datix last year of the same incident – why has this happened again and why don’t I know?" It was true, there were a few similar incidents last year and an action plan was put in place to mitigate another incident like this happening again. All the old policies were to be removed from the infonet and replaced with the updated versions. Not only this, the Trust was now moving towards a web-based search facility that enables the clinician to have all the updated evidence for policies, antibiotic therapies, prompt charts, documentation and prescribing advice. The guide would be updated and the old policies would automatically be replaced, thus mitigating clinicians using out of date policies and procedures. The document management system was put in place to ensure it is easier to do the right thing. So, if this forcible function was in place, how did this incident happen again? Not all staff know about the new document system. Some nurses think this search facility is for doctors only. Nurses are prohibited to use their mobile phones on the ward. Clinicians not always able to get to a computer. It takes too long to update when opening the browser – therefore people are using it offline. The final point is an interesting one. Making it easy to do the right thing is one of a number of aspects that a safe system is comprised of; however, if part of that system i.e. the Wifi is not set up to support the change, that system is at risk of a ‘work around’. Work arounds are what healthcare staff do to enable them to get through that shift without immediate detriment to themselves or the patient, make swift complex decisions easily and to ‘tick the box’. Time is a precious commodity, especially when you are a frontline worker. We know the document management system will have the updated policy; we wait for the download. We wait. We wait a bit longer. Eventually it loads. Remembering it takes a long time, we save it and use it ‘offline’ for future access. By using the guide offline makes it quick and easy. We are using Trust policy; however, that policy may now be out of date. So what? Implementation of this online guide was made to make our lives easier and safer for patients and ourselves. Due to an oversight of how clinicians ‘actually’ use and interact with this change in the work environment, it could have an adverse outcome for patients. How would the safety team know this was happening? Near misses seldom get reported. Chance meetings in corridors, chance conversations overheard, a reliance on staff that may know the answer – if we ‘fixed’ the problem for that near miss, why should we report it? No harm came to the patient after all. We have a good culture of reporting in the Trust; however, our safety team are overwhelmed with incidents to investigate. The current system is set up to investigate when harm has happened rather than seeking out ways to prevent harm. I’m part of the problem, so I can be part of the solution? I would welcome any support on this. Does anyone have any solutions or strategies in place where frontline staff are involved in the reporting of near miss events and are part of the solution to mitigate them?

Key learning points Two approaches to the problem of human fallibility exist: the person and the system approaches. The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness. The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects. High reliability organisations—which have less than their fair share of accidents—recognise that human variability is a force to harness in averting errors, but they work hard to focus that variability and are constantly preoccupied with the possibility of failure.