Introduction
If you are a healthcare worker and anything like me, you fear the prospect of being asked to contribute to an investigation that follows a patient safety incident (PSI). An email lands, your bleep sounds, or a colleague approaches you in the corridor; “Do you remember that patient, Mrs _____, the one who died, well there’s going to be an investigation…”
Your mind leaps back to the moment, weeks or months ago, when you realised that this patient had come to harm. It could have been a missed diagnosis, the delayed recognition of a biochemical abnormality, a procedural error, the wrong drug… You remember now. You were involved, but… there were others, it wasn’t just you. It was an incredibly busy night. The registrar was somewhere else, unable to help. It wasn’t any single thing you did. The whole situation was a mess.
What will they ask? Are you to blame, or was it the system? What is the system, anyway? A thousand individuals interacting in one building, each constrained by inadequate means of communication and dodgy computers… or a thousand hospitals in one nation, trying to share best practice, theoretically learning from one another, but each one essentially autonomous and unique in its methods? However careful the investigators are to approach this incident from the perspective of the system, you know it will feel like they are mainly interested in your role.
If the NHS is to improve, we must not be afraid to investigate PSIs. They are inevitable (maybe – we’ll explore that later), and so therefore are the investigations that follow. They are part of our lives as healthcare workers. If our lives are not to be destroyed by spikes of fear or apprehension, we must find a way to normalise these investigations. Depending on our luck (or our patients’ ill-luck) they may come along once every few years, perhaps once a decade, or perhaps more frequently as the threshold for looking into mistakes falls. It can only be a good thing if this threshold falls, as the opportunities for self-correction and improved clinical outcomes will become more numerous. I think of this as a kind of evolutionary pressure, each investigation representing an enforced mutation. Unsafe processes will fall by the wayside, and across organisations we will find better ways to do things. For this to happen we must all be engaged, not just grudgingly compliant with requests to provide an ‘account of events’.
For trainee doctors and senior colleagues to want to contribute, there must be some form of inducement or broader motivation. This may be an intrinsic, highly laudable sense of engagement with patient safety ideals, or it may be formal recognition of the time and effort that they put into it. The first hurdle, perhaps, is to take the sting out of that email or telephone call. Later, it might be possible to develop ways of recognising an individual’s overall contribution to improvements in patient safety. But for now, it would be an advance to see people prioritise and actively seek involvement in PSI investigations.
There is a huge literature around PSIs. Those who are interested can spend days reading about the different types of investigation, their strengths and weaknesses, their theoretical basis and how they were developed. I have seen various models applied in healthcare, from traditional root cause analysis (RCA), to ‘fishbones’ and ‘5-whys’, and each time I have come away thinking that they are artificial constructs into which facts and conclusions are be folded and forced. Of course, you can’t just spill a narrative onto the page, as those who read it will then have to do the hard work of establishing what factors were truly responsible for the negative outcome. On the other hand, life is not always amenable to a sequential analysis or compartmentalisation into predetermined categories. Some decisions remain inexplicable, and combinations of circumstances evade all reasonable explanation. To learn, it is necessary to understand how an organisation or a team functions, and how certain systems or individuals responded to certain facts or inputs, but even then it is often difficult to conclude that a single change or action will guarantee no repeat should the same set of circumstances occur.
At the end of every PSI investigation, we look to those actions as proof that we have responded and made progress. Completing those actions can be fiendishly difficult, and it is not uncommon for some of them to remain ‘pending’ for months or even years. Changing things is hard.
The more investigations I lead or review, the more strongly I have come to feel that the separation from the people who ‘deliver’ health care risks rendering them irrelevant. The learning cycle can take so long, the relevance of any actions has often evaporated by the time they are published. The work of compiling reports and bringing a degree of order to the chaos of real life is often done by those who work away from the front line. Doctors and nurses are needed on the wards, obviously, and cannot be spared. If their weekly work involved more consistent engagement with the process of learning, their consciousness would be more aligned to risk. Rather than becoming acutely aware following occasional emails or phone calls, they would develop a continuous sensitivity to the ever-present risks presented by the complex and changing environment in which they have chosen to work.
What is the Golden Thread?
It is a beguiling term, first used (as far as I am aware) in a communication from the then Secretary of State for Health and Social Care, Rt Hon Jeremy Hunt, who made patient safety a personal priority. In response, Aiden Fowler, NHS National Director of Patient Safety, wrote,
The Secretary of State asked us to develop a new Strategy for Patient Safety as a ‘golden thread’ running through healthcare. We consulted you on a set of ideas in December 2018 and you were clear and generous in your responses…. We received 527 contributions from organisations and individuals (staff, patients and carers). We attended stakeholder meetings and engagement events. We held workshops with staff, patients and senior leaders across the country. We hosted online discussions. We have listened and changed our plans.
From this work came a new Patient Safety Strategy, and within this, the Patient Safety Incident Response Framework (PSIRF). This describes a different approach to the investigation of medical accidents and avoidable deaths. PSIRF answers some of the objections to classical investigation methods that I have mentioned, and it will be interesting to see how hospitals adopt its principles. I explore some of its methods in later chapters.
This book imagines the golden thread as several things. It is a strong line that joins numerous parts of the NHS, ensuring that safety does not sit outside or alongside, but is part of every decision and action. The thread is ubiquitous, such that its glow should catch the attention of every healthcare worker, suffusing their every-day activities. It should be designed into the pattern of every new pathway, procedure or structure.
These are admirable aspirations, but we all know that other factors are continuously working to impede them. This book describes those factors – time pressure, expediency, human nature, money, even politics – and attempts to look beyond them towards a realistic future where safety is maximised. As I write this introduction, the new patient safety strategy and PSIRF are not yet embedded. As its authors accept, a new framework is only half the solution to better safety; culture is equally important, and culture means how people feel, what people regard as important, and how far they are prepared to go to prioritise safety.
This book attempts to explore the challenges presented to healthcare workers by the need to understand, process and learn from PSI. It looks at learning from the perspective of the busy doctor, nurse or administrator who just wants to get on with their job and feel good about what they are doing. It will attempt to reconcile learning, which can be painful, with a positive and optimistic approach to delivering patient care. It will also address the specific task of keeping patients, and their relatives, fully informed. In attempting to provide insights into these areas, I will describe several PSI, suitably anonymized or entirely fictional, and I will examine investigations and controversies that have entered the public arena. By their nature, these involved single or multiple tragedies, but the lessons – often involving candour and honesty – are applicable to all health systems.
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