Baroness Cumberlege’s report ‘First Do No Harm’ gives everyone involved in healthcare a lot to think about. The report examines the consequences of the use of Primodos, Sodium Valproate and pelvic mesh. It highlights serious failings and describes the industry’s response as “disjointed, siloed, unresponsive and defensive”. The reader is left with the dispiriting feeling that the progress that we all hoped was being made in patient safety in recent years amounts to nothing.
Most controversial, perhaps, are the report’s recommendations as to what to do about this. They include the setting up of an independent Patient Safety commissioner, outside the healthcare system, whose responsibility it is to represent the interests of patients.
While Baroness Cumberlege has done a great service by bringing out these issues and making the voices of those effected heard, it is less clear that the solutions she advocates are correct.
There are two fundamental questions here:
- Why do things go wrong?
- What can we do to stop them going wrong in the future?
These are big questions, but we at Verita, have some suggestions from what we have learnt in our extensive experience of investigating.
There are obviously a variety of factors which cause things to go wrong – and mistakes are an inevitable consequence of a complex system with people at its heart. That is not to say that the individuals are to blame – we know that people will never perform like computers. So we need to put systems in place to ensure that problems are identified before they turn into incidents and it is made easy for individuals to do the right thing first time.
This requires action at two levels – the individual and the system.
Any healthcare role involves not only providing care, but being responsive to thinking about how the system can be improved. Time and time again we see situations where someone knew something was wrong but were not able to do anything about it. That is not because they don’t care, but because they don’t feel empowered to resolve the problem themselves. Creating a culture where individuals feel listened to and empowered to bring about change is therefore essential. That comes from the top.
When individuals have spoken up there needs to be action. That requires organisations to understand what has happened, take responsibility for it and act to fix it. Two things are essential for that – they need the courage to act, but most importantly they need the data to make informed decisions. Fortunately, technology offers exciting opportunities in providing that data so that action can be taken.
Improving patient safety ultimately requires those at board/executive level to act – just as much as each individual involved in patient care. Whatever commissions, agencies, watchdogs or ombudsmen are set up, these realities won’t go away