In order to improve patient safety, it is essential to learn from serious incidents. Much has been written about the need to develop an open and fair culture to promote the reporting of serious incidents yet unfortunately I still hear about blame when staff are punished for making mistakes at the sharp end. This creates a climate of fear. Staff can become frightened of disciplinary action by their employer and the regulatory bodies. Fear leads to closed, non-learning cultures, where blame is equated to punishment.
“Patient safety is the avoidance of unintended or unexpected harm to people during the provision of healthcare. We support providers to minimise patient safety incidents and drive improvements in safety and quality. Patients should be treated in a safe environment and protected from avoidable harm.”
To counter this, the investigative process needs to focus on getting beyond the mistakes that have happened at the sharp end to look at underlying systems rather than individuals.
NHS Trusts need to ensure that the recommendations from serious incident investigations address system failures. Trust boards need to take a lead in promoting an open and fair culture by embodying values that are consistent with openness and fairness.
Patient safety will only really be improved when NHS trusts take steps to promote and develop an open and fair culture.