from a blame culture to a safety culture: the nhs in transition john lilleyman medical director npsa
TRANSCRIPT
![Page 1: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/1.jpg)
From a blame culture to a safety culture: the NHS in
transition
John LilleymanMedical Director
NPSA
![Page 2: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/2.jpg)
• Part of the UK National Health Service since 2001• Collects confidential national data on medical errors
and safety incidents• Covers England and Wales (53 million population)• Issues alerts and notices to hospitals and primary care
about safer practice• Works on designing safer systems of healthcare• Is not a regulatory or investigative body
National Patient Safety Agency
![Page 3: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/3.jpg)
Traditional NHS culture
• Person based approach to error• The punishment fallacy
– Punishing staff when they err will make them less likely to do so
• The perfection fallacy– Staff will avoid making errors if they try hard
enough
![Page 4: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/4.jpg)
![Page 5: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/5.jpg)
Consequences of traditional NHS culture
• Cover up
• Close ranks
• Admit nothing
• Tell no one
• Pretend nothing happened
![Page 6: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/6.jpg)
Barriers to moving from a blame culture in the NHS
• Changes in society• Changes in litigation• Professional silos
![Page 7: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/7.jpg)
Society ismore fragmented and self-centred
• Family and moral values• Social behaviour• Social mores• Less influence of religion
![Page 8: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/8.jpg)
‘In the Absence of GodBlame has become our
Prevailing religion’
Simon JenkinsThe Times 31 Dec 2004
![Page 9: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/9.jpg)
• ‘The trouble is that having abandoned the concept of the ‘act of God’, we have also abandoned its secular equivalent – the accident’.
• ‘Having replaced them with free will and human agency, we expect that agency to perform. When it fails to do so it (someone) must be declared at fault’.
SIMON JENKINS
![Page 10: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/10.jpg)
And the lawyers?
‘Litigation culture ischanging traditional lifestyles. Unless thegovernment actively
steps in to do somethingabout it, it could run
rampant’
Christopher Fairfax, Barrister, Tyler Law
![Page 11: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/11.jpg)
Manslaughter:The rising tide
• 1970-1990 4 prosecutions• 1990-2004 28 prosecutions
• Conviction rate for doctors 25%• Conviction rate overall 87%
![Page 12: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/12.jpg)
Increase in manslaughter charges for doctors due to
• Change in CPS attitude to gross negligence or recklessness at work in 1990s
• Growing social intolerance of medical errors
![Page 13: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/13.jpg)
‘Gross negligence’ manslaughter has 4 components
• Duty of care to the deceased existed• That duty was breached• Death was caused by that breach of duty• Breach was so great as to be considered gross negligence
and therefore a crime
![Page 14: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/14.jpg)
Richie Williams
Dr Murphy Dr Lee
![Page 15: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/15.jpg)
Latent errors in vincristine case
• Not starved, put to end of list• Wrong ward, inexperienced nurses• Drugs taken to theatre together• Rest of list finished, doctor i/c had to leave• Anaesthetist assured procedure straightforward• Prescription difficult to interpret
![Page 16: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/16.jpg)
![Page 17: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/17.jpg)
![Page 18: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/18.jpg)
NASOGASTRIC TUBE ERROR
Hiral Hazari aged 23 in first PRHOjob charged with killing by failing tonote NG tube misplaced in lung. Youngest doctor charged so far.
Katherine O’Reilly died from lung damage
![Page 19: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/19.jpg)
More Luer troubles
Dr Falconer fatally injected air into an IV line instead of an NG tube during surgery for pyloric stenosis on Aaron Harvard aged 6 weeks.‘A broken man’, he was acquitted.
![Page 20: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/20.jpg)
Features of recentmanslaughter cases
• All of the doctors intended to help patients• All were victims of system failures• All were devastated when faced with what they had
done• ‘Recklessness’ is hard to identify in the media reports• Institutional learning not shared
![Page 21: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/21.jpg)
Systematic failures(Reason’s ‘latent pathogens’)
• Weak safety culture• Inadequate operational practices• Lack of explicit protocols• Lack of experience/training• Communication failures• Poor equipment design
![Page 22: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/22.jpg)
Professional silos
![Page 23: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/23.jpg)
silo noun (pl. -os)
• 1 a tall tower or pit on a farm used to store grain. n a pit or other airtight structure in which green crops are compressed and stored as silage.2 an underground chamber in which a guided missile is kept ready for firing.ORIGIN mid 19th cent.: from Spanish, via Latin from Greek siros ‘corn-pit’.
![Page 24: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/24.jpg)
MDTs
![Page 25: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/25.jpg)
• Change ‘climate of blame, acrimony and confrontation’
![Page 26: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/26.jpg)
BUT HOW TO CHANGE?
• EDUCATION– Understand why and how people err– Recognise healthcare as a high risk industry
• Work in teams• Report and learn• Aspire to open and fair culture, not no-blame• ‘Making Amends’
– System of redress
![Page 27: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/27.jpg)
Engage the professions
• ‘Changes in process, structure or policy that are supported and driven by the clinical workforce are far more likely to achieve lasting success than those perceived to be imposed on service providers by a distant administration’.
– BAMM 2005
![Page 28: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/28.jpg)
Be patient
• Cultural change takes time• It proceeds patchily with hares and
tortoises• It requires leadership and enthusiasm
![Page 29: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/29.jpg)
What goes around comes around
‘It still tastes awful’
![Page 30: From a blame culture to a safety culture: the NHS in transition John Lilleyman Medical Director NPSA](https://reader035.vdocuments.us/reader035/viewer/2022081504/5697bf741a28abf838c7f8ee/html5/thumbnails/30.jpg)