Healthcare is enormously complex – as medical technology develops it is getting evermore complex. We should not be surprised when things go wrong – indeed we should expect it and plan for it. We should be willing to speak up about it. Equally we should not expect there to be simple solutions to the problems we find. There are no quick fixes in this most complex of all systems.
Something I identified in the 2018 report Opening the door to change was the inherent conflict between safety as imagined and the reality of safety in health services. Frontline staff and patients experience the reality of safety, they see the risk played out every day in clinical services – but we often talk about services as though they were intrinsically safe – when something goes wrong, someone therefore must have made a mistake.
No. When something goes wrong, we are seeing the inherent risk in a complex system being manifested.
The responsibility on us is not to deny the risk, but to learn how to constantly reduce it. That is why it is so important that everyone, staff and patients alike, feel free to speak up about things that can and should be improved. The risks inherent in all healthcare mean that all services will have matters that warrant improvement, and these will only become known if everyone is able to speak freely about them.
Why do we so often fail to do this? Fundamentally, I think it is because of the disjunction between safety as described and safety as realised.
When something goes wrong, we react defensively. We deny there is a problem, if we can’t do that we deflect – we say that the event was an aberration or a one-off and there are no wider lessons to learn. If that doesn’t work, we blame. Not just blame the person who happened to be at the centre of the realised risk, but all or anyone where we can transfer the responsibility to. Blame is just a way of avoiding the responsibility to change, to improve, to make carer safer. If the issue is someone’s fault, there is no need to listen to people’s concerns. This defensive reaction also leads to a search for a simple solution, often a change of policy or process or a punitive response against individuals or organisations. We need a different approach. An approach that accepts the complexity and risk of health care and the fallibility of individuals.
Every safety event should be an opportunity to learn and improve. Learning needs to be built upon a supportive culture and a thorough understanding of safety science. It needs to be transparent and open to challenge to make sure it gathers all views, including those from patients and their families. It must create a culture where speaking up is not exceptional, but it is normal expected behaviour.
The good news is that there is a widespread recognition of these issues, and the best services already recognise that creating an open culture where people feel free to speak up is essential if they are to provide consistently safe care. Still too many services fear openness, fear admitting that safety can be improved. They still want to deny the risk inherent in providing modern health services. Staff themselves who experience the risks want to speak up about what can be improved, but the culture in these services does not encourage them to do so.
Speaking up in these circumstances is exceptional and takes courage. People are fearful of talking openly about what could be improved. The challenge for all of us is to work with services to help them change that culture and to support them in making speaking up normal behaviour. Only when services are honest about the risk inherent in their care and create a culture where they can talk openly about it will they be able to make services as safe as they could be.