Seeing the world in a different way

In one year 3,283 patients died through preventable error, in England alone

1 in 10 patients suffer some form of unintended harm

1 in 300 hospital admissions will die as a direct result of error

(Data from Parliamentary enquiry into Patient Safety 2009 and DH/NAO publications 2005-2009)Martin Bromiley

Yes I know this is difficult to believe but these facts set the tone for Martin Bromileys presentation on seeing the world in a different way.

This was part of a series of talks for the Innovation Month the council has been running throughout May.

Martin explained how the death of his wife at the hands of caring, highly qualified and experienced medical professionals led him to eventually found the Clinical Human Factors Group.

Their raison d’etre is the investigation of accidents in healthcare, how they happen and why, but most importantly not the ‘who’

Challenges within the NHS

You are 33,000 times more likely to die from clinical error than an airplane crash

This is because the aviation industry has been able to embrace error and create a feedback loop that improves safety. This has inevitably led to a culture shift of accepting human error as a factor in accidents and learning from those errors to provide better and safer systems.

Embracing error is difficult in the NHS as it has a very hierarchal setup due to the high levels of technical skills to be senior within the organisation. This presents difficulty for those less senior to challenge and those who are senior, to accept error on their part.

Learnings for the Council

We need to be more open about failure, not the who but the how and why.

If there is a failing i.e. in social care or children services, don’t wait till we receive a complaint, an FOI or are being sued, investigate because we want to understand and learn from the failing

Help people with the language to challenge colleagues and those more senior. This act alone gives permission to do so.

In turn help those more senior to develop the skills to listen to challenge

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