System, not human error: military training helps our medical teams

World Patient Safety Day, September 17 2022, is one of the World Health Organization's global public health days, aiming to raise awareness and understading of health issues and mobilise support for action

WHEN something goes wrong in healthcare the temptation is to find someone to blame – when that someone may be a doctor or nurse doing their best in overstretched or poorly-designed working conditions.  

I recently dealt with a case where a patient underwent the wrong diagnostic procedure – a consent form for another patient had found its way into the medical records. The consultant was ‘suspended’ while an investigation was undertaken (but reinstated soon after). I couldn’t quite fathom how this was allowed to happen, with all the processes in place, such as pre-theatre checklists and apparent safety nets – and it certainly didn’t seem fair to single out the individual doctor for multiple process failures. 

I champion a ‘systems approach’ to investigating clinical incidents, which looks at all the factors that contribute to poor care, not just those related to human actions and behaviours. Moving private healthcare towards a culture of shared learning, not blame, is one of the things the medical teams at AXA Health are passionate about. 

Dr Pallavi Bradshaw,
Deputy Chief Medical Officer, Medicolegal

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So when we got the chance to learn more about systems thinking from a company with a military aviation background that specialises in clinical investigations, there was a waiting list – we all wanted to learn how we could use ‘systems thinking’ in our own investigations and when reviewing provider reports following clinical incidents and complaints. 

Paul Davis of PD Consulting, a former Royal Navy pilot who has advised the Ministry of Defence and the NHS on accident investigations and patient safety, delivered the engaging two-day workshop.  

No system can be perfect, he explained, showing how it’s often humans who create safety in an imperfect system – people adapt their behaviour to compensate where procedures and practices are unclear or out of date, where technology and the working environment are poor, and where resources are scarce.  

When things go wrong, people may then be blamed for not following ‘due process’ – when it was the system that caused the problem, as in the example above. Only by understanding the system will we see why it failed, how we put that right, and how to prevent avoidable harm. 

When collecting evidence, we learned about sensitive investigative interviewing, treating patients and staff with dignity and compassion while ensuring their story is heard. We found that the investigation itself can become part of their restorative process. 

We also learned about structuring our analysis to create clear reports and recommendations, and how to support a ‘just culture’ by changing our language: rather than blaming and saying what should have been done, we can explain what did happen and why people made the decisions they did at the time. 

Sensitive interviewing can be part of the restorative process

We ended on how best to suggest changes to systems – rather than focusing on ‘re-educating’ people or creating more admin in the form of checklists or guidelines. 

Those who attended the training learned a lot and we can’t wait to put these techniques into practice. The Chief Medical Officer team will be championing systems thinking in private healthcare: we have an exciting opportunity this year in a new NHS framework for responding to clinical incidents (‘Patient Safety Incident Response Framework’ (PSIRF), part of the NHS Patient Safety Strategy, 2019), which we’ll be encouraging providers to adapt and implement – just as we are doing. We must all play our part in building a resilient, fair, and open culture which encourages learning and prevents avoidable harm.