Transcript Slide 1
Whistleblowing Summit
Professor Jane Reid
Kohn 1999
Donaldson 2000
2007
2001
20052009
2011
• “where the offence is not to make a mistake, but to
ignore an error or, even worse, to cover it up”
• where speaking up and challenge are seen as
integral to safety and improvement within the
organisation
• “patient safety above all else through a culture of
high reliability”
Secretary of State for Health's speech - 'My ambition for patient-centred care‘
8th June 2010
Columbia 1983
Challenger 1986
“ The organizational causes of this accident are rooted in the Space
Shuttle Program’s history and culture….
…Cultural traits and organizational practices detrimental to safety were
allowed to develop and were normalised, including:
• reliance on past success as a substitute for sound engineering
• organizational barriers that prevented effective communication of
critical safety information and stifled professional differences of
opinion …”
DH Human Factors Reference Group
commissioned December 2010 by Sir Bruce Keogh
“enhancing clinical performance through an
understanding of the effects of teamwork,
tasks, equipment, workspace, culture,
organisation on human behaviour and
abilities, and application of that knowledge in
clinical settings”.
Catchpole K (2012)
Clinical Human Factors
• Greater acceptance that to err is human
• HF and safety more commonly discussed
• Greater use of Team ResourceManagement and Notechs
• HF starting to be built in to early education
• Standardisation more widely appreciated
• Understanding the human is increasingly recognised
as key to shifting the culture
• Some Trusts starting to employ HF specialists
• Examples of clinician led safety groups reporting
directly to Board level
• GMC & NMC produced a joint statement of
professional values recognising the essential role of
“notechs”
BUT…………..
• HF viewed too narrowly as “teamwork”
• Equipment standardisation left to chance
• It’s still easy to blame the clinician not the
system
But....
• SUI’s “done to deadline”.....and then filed with
no human factors insight
• Most processes still assume human perfection
• Professional leaders often reluctant to
challenge clinicians and set standards
Lessons from Human Factors Research
• errors are common
• the causes of errors are known
• organisational culture determines the level of
reporting and speaking up
• integrate systems and /triangulate data
Department of Health
Human Factors Reference Group
Interim Report
1 March 2012
“...(We) need to integrate and mainstream
human factors knowledge and understanding
in order to ensure consistent, sustainable
delivery of safer care for our patients.
Embedding this knowledge and understanding
is not an optional extra. There is clear
evidence from within and outside the NHS
that human factors are a significant factor in
disasters.”
Sir Stephen Moss
Mid Stafforsdshire NHS Foundation Trust
“We can’t change the human
condition, but we can change
the conditions under which
humans work”
James Reason
Equip the Board and ‘frontline’
•
•
•
•
•
•
•
Assertiveness
Communication
Conflict Resolution
Critical Language
Decision Making
Disclosure
Teamworking
• Leadership
• Normalisation of
Deviance
• Situational
Awareness
• Stress and Fatigue
• Error Mitigation
(checklists/standardisation)
Improvement is dependent on
•
system wide enablers
•
embedded organisational values
•
clear thresholds and tolerances
•
committed consistent leadership at all levels
Whistleblowing Summit
Professor Jane Reid