Search the hub

In the early days of my career, I worked with clinical teams while managing a hospital and later a network of hospitals. I must say, the experience I gathered in these different roles shaped me into what I am today. I can fit into healthcare conversations easily because of these early relationships and interactions with clinical experts. When I look back to my experience as a hospital administrator, a particular incident keeps coming back to mind; I sometimes link this to my later involvement in patient safety but most times I feel it is my conscience speaking to me. There was a patient we were trying to give a surgical intervention to; although he was already in a bad condition, he stood a chance to survive yet he died. We had an antenatal case we had managed from conception and the lady had opted for an elective caesarean section (CS). When she was term, we brought her in and prepared her for the theatre. At the time set of the surgery, our anaesthetist was not available; he was assisting another surgery in another facility, but he gave us a name of his anaesthetist colleague we could use for this patient. We brought this new anaesthetist in to assist in the patient’s CS. While we stretchered in the lady for her elective CS, a severe emergency case was rushed in needing an urgent surgical intervention. This case obviously had to override the elective CS in order of triage. We returned the lady to her ward while we rushed to the emergency case. The medical team that was going to operate on the CS patient was now needed for this new case. About 20 minutes into the surgery, our lead surgeon came out of the theatre with an upset look on his face. I sensed something was wrong and I immediately led him into my office which was near to the theatre and locked the door. I asked him what happened? He told me that there had been an anaesthesia accident. The new anaesthetist we brought in to assist with the surgery had not understood our anaesthetic machine as he had never used it before. He had used the machine incorrectly and had given the patient an overdose of gas and the patient’s heart packed up. The lead surgeon was very upset. I was thinking, this could have been my Dad, my Mum or any of my family members; it was a totally life-changing experience for me. The relatives of the patient were notified that the patient had died; there was wailing and shouting in the hospital. I locked myself inside my office and cried because I knew this patient should not have died from an error of one man. I imagined the pain we had caused the family; the grief and the vacuum we created by our error. It was all too much horror for my fragile heart to deal with at that time. But the greatest mistake we made was that the error was never discussed among the team for us all to learn from and we were also not honest enough to own up to the patient’s relatives. This incident led me into researching and reading materials on medical safety and this was how I got into patient safety advocacy. But when I look back at the incident today, was it the anaesthetist’s fault? No not at all; it was the fault of the system. The anaesthetist should not have been allowed access to that machine in the first place as he had not been trained to use that machine. This was where we should have trapped the risk before it got to the patient. In safety, when you change or replace a machine or a piece of equipment your policy must be reviewed to capture the new equipment and users must be trained on the new machine in its specifications and peculiarities. This is what happens in aviation. A pilot cannot fly an aircraft which he has not been simulated to fly and this is one of the reasons why aviation is still one of the safest sectors in the world today.[1] Having established that it was a system error, we should have also been professional and honest enough to let the relatives of the patient know what had actually happened. When we are honest it shows clear transparency, but when we try to sweep things under the carpet it is mostly misunderstood that our actions could have been deliberate. As I am writing this article, I am sure the relatives of the patient, many years down the line, still don’t know what actually happened. Following the Communication and Optimal Resolution (CANDOR) processes,[2] we should have made an early and honest disclosure of the adverse event known to the patient’s relatives, offered them an apology, refunded their payment and let them know how much this mattered to us and what we were going to do to improve our system. Our actions totally contravened all required amicable and fair resolution for the patient’s family. Owing to the fact that every man is fallible – this is why we are mere mortals in the first place – there may be errors but losing the opportunity to learn from those errors is deliberately creating new levels of errors. We never discussed what happened to our patient. I was the only one who got to know about this incident outside the clinical team who were in the theatre when this happened. The Medical Director may not have even known, so the case was never discussed and we could never all learn from it. When I think of this, I feel we need more openness and information sharing in healthcare, allow teams to discuss and share experiences, give room for reporting without blame, design a system that encourages patient safety conversation and liberalise communication processes. Each time this incident crosses my mind, I think of the lady who we had originally booked for elective CS. This clinical team was put together for her CS before the sudden emergency that came to take her place. She never knew what happened. The evening of that same day her CS was done and she had her baby boy who should be a grown man now. This brings to mind the bible verse Isaiah 43.4 “…I will give people in exchange for you, nations in exchange for your life”. Could this have been what happened? No, the system is what killed the patient and I think we should all own up to this. References Kai-Jorg S. Pilot training: What can surgeons learn from it? Arab Journal of Urology 2014;1: 32-35. Agency for Healthcare Research and Quality (AHRQ). Communication and Optimal Resolution (CANDOR).

This virtual masterclass, facilitated by Mr Perbinder Grewal, will focus on patient safety and how to setup a proactive safety culture. It will look at what patient safety is and how to setup and improve the safety culture. It will look at Human Factors and how to mitigate some of the common errors. Can we have a system with zero patient safety incidents or errors? Further information and book your place or email kate@hc-uk.org.uk hub members receive 10% discount. Email info@pslhub.org for code

This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) which has now been published for the early adopter sites as introductory guidance. NHS Improvement will then work with a small number of early adopters to test implementation. For all other organisations the PSIRF is being published for information only and using learning from the pilot sites, resources and guidance will be developed to support organisations to adopt and implement PSIRF, with an expectation that providers and local systems will begin introducing the new framework from Autumn 2020, with full NHS-wide roll out complete by Summer 2021 (these timings are subject to change due to Covid-19). The conference will also update delegates on best practice in Learning from Deaths the role of the Medical Examiner. There will be an extended focus on learning from serious incidents, ensuring the investigation findings lead to change and improvement. Register

Bullying and scapegoating ride on the back of fear: When things go wrong or have an outcome that we were not anticipating different aspects of second victim phenomenon kick in, such as shame, guilt and fear. It is terrifying to fear for the loss of one’s professional registration or to be recognised as the care worker who damaged the reputation of your organisation. Quite apart from the pain and accompanying worry of knowing that you may have brought harm to your patient. Encouraging openness and honesty, permits emotional healing, supports staff retention and reduces the number of safety incidents. Emotional healing rides on the back of openness and honesty: In order to move on from a safety incident, it is essential to be truthful. Recognise that peoples’ perceptions of an incident are subjective and may differ from your own. Perceptions often germinate during a time of chaos. Refrain from judging, instead focus on your own personal recovery. Draw strength and comfort from your courage to speak the truth as you perceive it. No such thing as a Never Event: The use of the term ‘Never Event’, increases feelings of guilt and shame for those of us unfortunate enough to be associated with a safety incident. We are, at the end of the day, human beings working within a system of systems. There can never be such a thing as a Never Event. The term second victim is out dated: It degrades the trust that patients and families place in us as care givers. I suggest the term PIAE as an alternative. People In Adverse Events. Not all PIAEs will be involved in a review process. The majority won’t. Sometimes simply seeing something is sufficient to cause psychological trauma for a care worker. All PIAEs should have access to tiered emotional support. This is my challenge to the NHS. Finally the biggest challenge I faced on my amazing journey, was helping people to understand that PIAE support is not competing with other support initiatives. It is a specialised area, providing timely, empathetic, non-judgmental support by trained Listeners, for a specific group of people, namely PIAEs. Read Carol Menashy's other blogs on SISOS: Part one Part two Part three Part four