Safety culture – learning from serious incidents

Verita is an independent team providing investigations consultancy work with organisations in a variety of sectors throughout the UK

Serious incidents

The tragic crash of the Germanwings flight 9525 from Barcelona to Dusseldorf got me thinking about how different organisations learn from serious incidents and how quickly they are able to adapt and put barriers in place to reduce the likelihood of similar disasters.

The Germanwings plane crashed on 24 March 2015 and in response to the incident – aviation authorities in Canada, New Zealand, Germany, and Australia implemented new regulations that require two authorised personnel to be present in the cockpit at all times.

Similarly, just three days after the incident, the European Aviation Safety Agency issued a temporary recommendation for airlines to ensure that at least two crew members, including at least one pilot, are in the cockpit at all times of the flight. Several airlines announced they had already adopted similar policies voluntarily.

I was struck by the how rapidly the aviation industry implemented a barrier to reduce the likelihood of recurrence.

Healthcare – like the aviation industry – would describe itself as a high-reliability organisation (HRO). HROs are organisations that work in situations that have the potential for large-scale risk and harm, but manages to balance effectiveness, efficiency and safety.

There has been little exploration of the links between high reliability and safety culture – or whether developing specific characteristics of HROs also leads to an improved safety culture. The literature tends to assume that HROs have a positive safety culture and this is often deemed to be one of the characteristics of those organisations.

While healthcare is extremely complex and we often don’t have data to support investigations (such as that stored in a plane’s black box) there are instances when trusts are slow to get to grips with the root causes of incidents. When a thorough investigation has been conducted trusts can struggle to implement sustainable change in a timely way.

We’d be horrified to learn that a pilot had not gone through the pre-takeoff checklist while on the ground. Yet, it is somehow deemed more acceptable that a surgeon would undertake an operation without completing the WHO surgical checklist.

Although there are lots of examples of good practice within the health service – we have more work to do to fully embrace a patient safety culture.

If you would like to learn more about serious incidents then please contact Ed Marsden on 020 7494 5670 or [email protected].


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