Learning lessons from errors

Public hospital horror stories will always arise. Hospitals operate in life and death zones in the midst of medical complexity and human interaction. There is a lot that can go wrong.

It is encouraging, therefore, to learn this week reported instances of harm in Southern District Health Board hospitals have fallen by 25%. The 2011-12 "serious and sentinel" report showed Southern had 30 events, 10 fewer than the previous year.

There were six deaths, although these were not necessarily because of the reported incident.

Southern's patient services medical director Dick Bunton claims the fall is not because of a reluctance to report incidents but rather because enhancements are taking place. Lessons are being learned from past errors, and procedures are improving. People could infer from the drop in cases that public hospitals in the South were becoming safer. Hopefully, Mr Bunton's comments reflect what is happening and are much more than just positive spin.

Hopefully, too, improvements continue.

The key, it seems, to effective reporting and continuous progress is banishing a blame-and-shame culture. If staff are fearful they will not raise issues. If mistakes are buried and backs covered, problems will remain hidden and solutions cannot be found.

Inevitably, however, this is easier said than carried out in practice. It is always difficult to admit errors for reasons of pride, guilt, shame, career advancement and sometimes culpability consequences. Yet, that has to be done.

Staff have to know it is their duty to report when things go wrong.

And supervisors and the hospital hierarchy have to deal with these situations with tact and skill.

Running in parallel must be "robust" reporting systems. Those who might be reluctant to come forward need to feel they have little choice. They know that someone else will be reporting some aspect of the incident so they might as well be up front.

Complicating matters, too, is the fact in any organisation - let alone one with thousands of employees - there will always be staff who, for various reasons, are not up to the job. They are likely, not surprisingly, to be particularly defensive about adverse events.

And there will be a few occasions where sympathy and understanding towards staff is no longer appropriate.

Overall, however, Mr Bunton said the combination of a medical culture that was less likely to hide mistakes and the "robust" reporting systems had led to improvements. Rather than fear criticism, incidents were much more likely to be reported. The six years of reports and their follow up had helped change attitudes.

All involved realise, as they should, that every incident is one that should not have happened, that every instance affects the lives of individuals, that - as Health Quality and Safety Commission chairman Prof Alan Merry has said - every event has "a name, a face, and a family", and that should never be overlooked.

In Southern's case, the unnecessary mastectomy, the death of a patient after CPR was not administered because of an incorrect assumption about a "not for resuscitation" order, the tumour identified as an incidental scan finding and not followed up and the other incidents, indeed, are horror stories for those concerned.

Of course, human error will never be entirely eliminated, whatever the systems and procedures and however much everyone is doing their best. What can be achieved, nevertheless, is progress towards the ideal of eliminating all such events.

Those who introduced the reporting systems can be pleased at the progress. The next step, the commission says, is to increase the range of organisations subject to future reports, perhaps to include private hospitals (where it is good to see Mercy Hospital voluntarily leading the way), hospices, ambulance and care agencies.

An additional challenge will be to combat the fear of bad publicity in private and/or competitive fields. It is easier for what some might see as "dirty linen" to be aired in public with a public body rather than a private provider.

Given, though, the heartening success of the events reporting system for public hospitals, efforts should be made to extend its reach. Every "horror" story that can be avoided is one less instance of pain and heartbreak.



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