What a mess. There’s flour all over the kitchen floor. A fortnight ago I opened the cupboard to get sugar for my hot chocolate. As I pulled out the sugar, it knocked against the bag of flour which was too close to the edge… Luckily the bag didn’t burst and I cleared it up quickly before anyone found out. Now it’s two weeks later and exactly the same thing just happened to my brother. This time the bag did burst and it went everywhere. Now he’s in big trouble for being so clumsy!

In safety-critical industries, like healthcare and the airline industry, especially, it is really important that there is a culture of reporting incidents including near misses. It also, it turns out, is important that the mechanisms of reporting issues is appropriately designed, and that there is a no blame culture especially so that people are encouraged to report incidents and do so accurately and without ambiguity.

Was the flour incident my brother’s fault? Should he have been more careful? He didn’t choose to put the sugar in a high cupboard with the flour. Maybe it was my fault? I didn’t choose to put the sugar there either. But I didn’t tell anyone about the first time it happened. I didn’t move the sugar to a lower cupboard so it was easier to reach either. So maybe it was my fault after all? I knew it was a problem, and I didn’t do anything about it. Perhaps thinking about blame is the wrong thing to do!

Now think about your local hospital.

James is a nurse, working in intensive care. Penny is really ill and is being given insulin by a machine that pumps it directly into her vein. The insulin is causing a side effect though – a drop in blood potassium level – and that is life threatening. They don’t have time to set up a second pump, so the doctor decides to stop the insulin for a while and to give a dose of potassium through a second tube controlled by the same pump. James sets up the bag of potassium and carefully programs the pump to deliver it, then turns his attention to his next task. A few minutes later, he glances at the pump again and realises that he forgot to release the clamp on the tube from the bag of potassium. Penny is still receiving insulin, not the potassium she urgently needs. He quickly releases the clamp, and the potassium starts to flow. An hour later, Penny’s blood potassium levels are pretty much back to normal: she’s still ill, but out of danger. Phew! Good job he noticed in time and no-one else knows about the mistake!

Two weeks later, James’ colleague, Julia, is on duty. She makes a similar mistake treating a different patient, Peter. Except that she doesn’t notice her mistake until the bag of insulin has emptied. Because it took so long to spot, Peter needs emergency treatment. It’s touch-and-go for a while, but luckily he recovers.

Julia reports the incident through the hospital’s incident reporting system, so at least it can be prevented from happening again. She is wracked with guilt for making the mistake, but also hopes fervently that she won’t be blamed and so punished for what happened

Don’t miss the near misses

Why did it happen? There are a whole bunch of problems that are nothing to do with Julia or James. Why wasn’t it standard practice to always have a second pump set up for critically ill patients in case such emergency treatment is needed? Why can’t the pump detect which bag the fluid is being pumped from? Why isn’t it really obvious whether the clamp is open or closed? Why can’t the pump detect it. If the first incident – a ‘near miss’ – had been reported perhaps some of these problems might have been spotted and fixed. How many other times has it happened but not reported?

What can we learn from this? One thing is that there are lots of ways of setting up and using systems, and some may well make them safer. Another is that reporting “near misses” is really important. They are a valuable source of learning that can alert other people to mistakes they might make and lead to a search for ways of making the system safer, perhaps by redesigning the equipment or changing the way it is used, for example – but only if people tell others about the incidents. Reporting near-misses can help prevent the same thing happening again.

The above was just a story, but it’s based on an account of a real incident… one that has been reported so it might just save lives in the future.

Report it!

The mechanisms used to do it, as well as culture around reporting incidents can make a big difference to whether incidents are reported. However, even when incidents are reported, the reporting systems and culture can help or hinder the learning that results.

Chrystie Myketiak at Queen Mary analysed actual incident reports for the kind of language used by those writing them. She found that the people doing the reporting used different strategies in they way they wrote the reports depending on the kind of incident it was. In situations where there was no obvious implication that a person made a mistake (such as where sterilization equipment had not successfully worked) they used one kind of language. Where those involved were likely to be seen to be responsible, so blamed, (eg when a wrong number had been entered in a medical device, for example) they used a different kind of language.

In the former, where “user errors” might have been involved, those doing the reporting were more likely to write in a way that hid the identity of any person involved, eg saying “The pump was programmed” or writing about he or she rather than a named person. They were also more likely to write in a way that added ambiguity. For example, in the user error reports it was less clear whether the person making the report was the one involved or whether someone else was writing it such as a witness or someone not involved at all.

Writing in the kinds of ways found, and the fact that it differed to those with no one likely to be blamed, suggests that those completing the reports were aware that their words might be misinterpreted by those who read them. The fact that people might be blamed hung over the reporting.

The result of adding what Christie called “precise ambiguity” might mean important information was inadvertently concealed making it harder to understand why the incident happened so work out how best to avoid it. As a result, patient safety might then not be improved even though the incident was reported. This shows one of the reasons why a strong culture of no-fault reporting is needed if a system is to be made as safe as possible. In the airline industry, which is incredibly safe, there is a clear system of no fault reporting, with pilots, for example, being praised for reporting near-misses of plane crashes rather than being punished for any mistake that led to the near miss.

This work was part of the EPSRC funded CHI+MED research project led by Ann Blandford at UCL looking at design for patient safety. In separate work on the project, Alexis Lewis, at Swansea University, explored how best to design the actual incident reporting forms as part of her PhD. A variety of forms are used in hospitals across the UK and she examined more than 20 different ones. Many had features that would make it harder than necessary for nurses and doctors to report incidents accurately even if they wanted to openly so that hospital staff would learn as much as possible from the incidents that did happen. Some forms failed to ask about important facts and many didn’t encourage feedback. It wasn’t clear how much detail or even what should be reported. She used the results to design a new reporting form that avoided the problems and that could be built into a system that encourages the reporting of incidents . Ultimately her work led to changes to the reporting form and process used within at least one health board she was working with.

People make mistakes, but safety does not come from blaming those that make them. That just discourages a learning culture. To really improve safety you need to praise those that report near misses, as well as ensuring the forms and mechanisms they must use to do so helps them provide the information needed.

Updated from the archive, written by the CHI+MED team.

More on …

• Machines and Medicine
• Diversity
• The women are still here

Magazines …

• Issue 17: Machines making medicine safer
• Issue 29: Diversity

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EPSRC supports this blog through research grant EP/W033615/1.