A National Forum on Safety and Quality in Healthcare opened in Canberra today, with the theme, Society, Regulators and Health Providers: a clash of expectations?
This is the second in a series of posts from speakers at the forum, in which a patient safety expert, Professor Jeffrey Braithwaite, Director of the Centre for Clinical Governance Research, Australian Institute of Health Innovation at the University of New South Wales, tells us what healthcare can learn from disasters.
Jeffrey Braithwaite writes:
When disaster strikes, it’s often the result of a cataclysmic error from at least one human being.
The Concorde disaster might have been avoided had the pilot not continued take-off after losing power; the Space Shuttle Challenger disaster was triggered by a lack of communication; and the Chernobyl nuclear disaster occurred after routine testing was aborted and the night crew were not notified.
Each of these disasters resulted in death, destruction and financial loss, but they have also served as useful points of learning for others, particularly within their industries.
Many people in health care often say healthcare is ‘different’ from other industries but I believe this attitude results in a missed opportunity to learn from others’ mistakes.
After all, ‘disasters’ occur regularly in our industry, where 10% of patients are harmed in hospital through adverse events or errors.
In a recent research project, Clifford Hughes from the Clinical Excellence Commission, my colleague Joanne Travaglia and I investigated six cases of human error drawn from disasters in a range of industries and how they might apply to healthcare.
We compared industrial and transport disasters with healthcare disasters and found a remarkably similar pathway, a generic and predictable sequence of events that might serve us well to investigate further.
What these disasters had in common was that they all involved a complex system, where things were bumping along and there was the potential for error, then something triggered an error, and this was followed by a decision which escalated the problem. At that stage, corrections may or may not have been attempted and finally a disaster culminated with direct and indirect consequences.
In the case of the Concorde crash, for example, a titanium strip on the runway caused a tyre to burst on take-off, which subsequently ruptured a fuel tank causing a fire and engine failure. Despite an excellent safety record, tyre ruptures were a known hazard.
The pilot made the decision to continue take-off despite an initial power loss, the tyre ruptured the fuel tank and the rest is aviation history — more than 100 people died.
In healthcare the potential for such an immediate cataclysmic disaster seems less likely, things can progress from relative stability to full-blown disaster as the result of one poor decision or a series of inactions.
A slow response from UK authorities to a blood product contamination, for example, resulted in that crisis continuing until 2,000 people with haemophilia died and more than 4,500 patients acquired hepatitis C with some also infected with HIV.
The Bristol Royal Infirmary disaster saw dozens of babies die from complicated heart surgery at twice the normal mortality rate of other hospitals, as the staff operated for a long time without a specialist cardiac surgeon.
People raised concerns for over a decade before anything was done – another common feature of disasters is that early warning signs and the individuals who raise them are often ignored or marginalised.
When conditions are not ideal, seemingly trivial events such as using the inappropriate procedure for acquiring a new blood product, or employing a new staff member, or discharging a patient could be the trigger for a disaster.
In healthcare we need to learn from others’ mistakes and while we can’t completely inoculate ourselves from impending disaster, we can at least keep our eyes wide open for the warning signs.
• For more from Jeffrey Braithwaite, this article in the Weekend Australian’s health section suggests our national health reform agenda is unlikely in itself to improve patient safety and outcomes.
The next post from the forum – which is hosted by the Australian Council on Healthcare Standards, ACT Health and the Australian Commission on Safety and Quality in Healthcare – will come from someone who has experienced healthcare harm first-hand and now advocates for others.
For the previous post in this series: