Systems thinking and safety

Dr David Sage, clinical lead for the Health Quality & Safety Commission’s national reportable events programme, looks at the increasing influence of safety systems on healthcare

For a typical New Zealand doctor such as myself, Casebook has been a must-read since its inception. When the stakes are high, actual cases teach very effectively.

So it is with interest that I note the articles in Casebook are increasingly using the safety systems language – in the recent May edition “Swiss cheese” appeared twice, and scattered throughout are the words “high reliability” (several mentions), “fail-safe”, “safety checklist”, “human error”, “human factors training”, “situational awareness” and “crew resource management”.

I was not surprised to see an exchange in the correspondence section between two doctors who between them were also qualified as an airline captain, patient safety and risk consultant, former surgeon and former paediatrician. This convergence of engineering systems thinking and safety development in healthcare is increasingly seen in New Zealand.

It is reflected at the HQSC in the recent appointment to the board of Bob Henderson, an active airline captain with a strong background in psychology, and expertise in human factors and aviation safety.

Being ‘open’

The HQSC is reinforcing this convergence by inviting US human factors expert Jim Bagian to visit New Zealand in November. Dr Bagian is, among other things, an engineer, anaesthesiologist, NASA astronaut, and private pilot. He also brings his experience as previous chief patient safety officer at the Department of Veterans Affairs, and is currently the director of the Centre for Healthcare Engineering and Patient Safety at the University of Michigan.

Dr Bagian suggests the biggest obstacle to improving medical safety is medical culture, rather than our understanding of the human body or the quality of the available technologies and treatments. He has firm ideas on the use of safety language in healthcare. For example, he advocates avoiding the ‘error, medical error, human error’ terms that have punitive overtones and can get in the way of developing safety conscious work cultures. This approach – promotion of a just culture that supports those who report adverse events and near misses and does not pursue public shaming – is at the heart of the HQSC’s Open for better care national patient safety campaign. It was an approach that was taken by one of New Zealand’s top companies in a high-profile case last year.

An Air New Zealand pilot fell asleep for a minute twice while cruising between London and LA. Both the airline and the Civil Aviation Authority of New Zealand strenuously rejected pressure to identify the pilot. The pilot remains unnamed and no charges were pressed because Air New Zealand considers reporting incidents of fatigue a part of increasing their safety culture. The HQSC supports transparency and an open approach. This is an area where doctors need to take the lead. We hope to learn from James Bagian’s Veterans Affairs reporting culture, in which fully 50% of all root cause analyses of incidents are from staff reporting near misses or close calls.

Systems that work: checklists

So the World Health Organisation Surgical Safety Checklist doesn’t apply to you because you are not a surgeon? Maybe not that particular list, but the principle applies across healthcare. The success of catheter-related CVC infection rate reduction to near zero in New Zealand intensive care units is due to the marrying of cockpit drill checklist safety culture and infection control science, to create a bundle of care that works if done the same way every time. So far that precision – the same way every time – hasn’t been achieved in New Zealand for the surgical checklist.

Voluntary incident reporting to the HQSC for the last two years shows perioperative harm events made up 36% of the non-mental health serious adverse events reported by district health boards to the HQSC in 2012-13. Those events included seven wrong patient, site or procedure cases. Gastroenterologists, interventional cardiologists and other proceduralists are also starting to think checklists, and the HQSC has case reports in these settings of wrong patient/wrong site that reinforce the need for checking systems every time.

The system of reconciliation

From time to time Casebook describes instances of missing pathology or imaging results that delay diagnosis or treatment. Over the past two years, the HQSC has received about 50 cases a year in the broad category of “case delay”. It is obvious there is a wide variety of causes, but human factors predominate in the breakdown of patient booking systems, lab and radiology reports going missing or getting swapped. Just as most clerical and cognitive prescribing lapses can be overcome with computerised prescribing, so too electronic reconciliation systems for pathology and imaging can allow tracking that dramatically reduces lost results.

The frequency of process delays in healthcare is not acceptable in an age where tracking and reconciliation of courier parcels or suitcases is near foolproof. The healthcare industry is learning a lot, and still has a lot to learn, from the engineering and aeronautics industries. As Dr Bagian says, the latter industries operate under conditions of high hazard yet seldom have a bad event – and people in those fields tend to have a systems perspective.

We can’t improve a system unless we know there is a problem with it, and a real positive is the increase in reporting of serious adverse events by the New Zealand public and private healthcare providers. This reflects a willingness to learn from events and contributes to a culture of transparency. It is difficult to prevent all harm in healthcare, but the medical profession must take the lead when it comes to learning from events, improving systems with systems thinking, and preventing at least some tragic healthcare events from recurring.