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Journalist and author of the acclaimed book Black Box Thinking — The Surprising Truth about Success, Mr Matthew Syed, has studied the psychological conditions of high performance in individuals, teams and institutions and addressed the Medical Council’s recent inaugural Patient Safety and Leadership Conference. He said he has found that those who believe in the primacy of innate talent over other factors can find it difficult to learn from their mistakes.
Comparing the aviation industry and healthcare — not a popular comparison, he acknowledged — he said that the former is far better at learning from errors.
He added that a culture of blame can be a barrier to learning but so too can be the attitudes of some senior clinicians. “There is something quite deep in clinical culture that when you become a consultant, then you’re pretty close to clinically infallible.”
Mr Syed stressed that this is not common to all senior doctors, “but I think it’s fair to say it is common to a critical mass”. This can establish a psychological barrier when there is a sub-optimal answer, ie, when a patient dies avoidably.
“In healthcare, there is a measurable tendency to evade. I think part of this is that it is threatening to the egos of senior clinicians who are acquainted with the idea that they are super talented, brilliantly clinically able to sort the problem out.
“So when there is a problem, there is a tendency to say ‘well, that’s nothing to do with us’.”
This can involve blaming the patient’s unusual symptoms, complications or just that it was “one of those things”.
Recounting his experience where he was invited to speak at the conference of a medical specialty, Mr Syed told the audience that a motion seeking to measure complications and examine potential solutions was rejected by more than 50 per cent of the doctors present.
“They were worried it would show them as less than perfect,” he said, describing it as a live psychological issue today.
Mr Syed pointed out that until very recently, 45,000 people died every year in the US because of central line infections, “not a controversial piece of data”, with the figures in the UK also very disturbing.
People were dying in plain sight, he said, because of the wrong mindset. Once these deaths were examined and a common mistake identified — staff not sterilising the catheter site — this fatality rate dropped to zero.
However, according to the Journal of Patient Safety, 400,000 US patients die every year because of preventable medical error, the third-biggest killer in the US.
The fear of being “hung out to dry” in the media for honest mistakes created by systemic faults means that clinicians are unlikely or less likely to volunteer information, Mr Syed stated.
“Looking from the outside in, after the event and with the benefit of hindsight, it is very easy to pin the blame on the professional nearest to the error.”
The advantage for management is, it looks muscular and decisive. However, this is ultimately self-defeating.
“If you blame the professional pre-emptively before the investigation, two things happen. One, the systemic flaw is still there, and two, the message is sent to everyone in the organisation to cover their backs.”
Escalating the consequences of the error will not make errors less likely. “This is a basic misapprehension about how to respond to errors in situations of complexity.”
The establishment of a ‘just culture’, where front-line operators and others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, is the way forward, Mr Syed maintained.
An organisation’s willingness to look into systemic factors leading to harm in advance of blame reassures those on the front line that they won’t be blamed unfairly, he said.
However, of all the industries he has worked in, which include the police and FTSE companies, healthcare today is the most defensive industry he has come across.
“Unless that changes, patient safety and high performance will remain an illusion.”
Also speaking on the topic of patient safety was Mrs Margaret Murphy, a lay member of the Council and the External Lead Advisor with the World Health Organisation’s (WHO) Patients for Patient Safety. She became a patient advocate following the tragic and avoidable death of her son Kevin in the health service and called for mandatory disclosure following errors.
Mrs Murphy said that she has met many front-line staff who want to do the right thing in the aftermath of an adverse event but are wary of putting their heads above the parapet. The fear is that by disclosing information to patients and their families, it will be used against them.
“Transparency and accountability are sacrificed on the altar of corporate damage limitation as a ‘deny and defend at all costs’ strategy kicks in.”
Patients and their families, she stressed, are not motivated by financial settlements and she also recognised the impact of second victim syndrome on staff and that the system had also abandoned front-line staff.
Adhering to the perception of ‘faultless performance’ was a contributing factor in this culture and she asked the audience to practise medicine “with head, with heart, with hand”.
Meanwhile, Colonel Eileen Collins, the first woman to pilot an American spacecraft, recounted the day the NASA shuttle Columbia exploded and how during the two-and-a-half years between the disaster and the return to flight, missed opportunities to avoid the tragedy were identified.
These included that software models had not been assessed against real-world testing. Changes in flight practices were also overseen, which meant that potential damage could be found while in space, she said.