No blame game: giving pharmacists a ‘safe space’ to discuss errors

Safety expert of a new investigative body talks to Abigail James about how its approach will enable pharmacists to be more transparent about errors.

Tracey Herlihey, head of safety intelligence at the Healthcare Safety Investigation Branch

The Healthcare Safety Investigation Branch (HSIB) is at the heart of UK health secretary Jeremy Hunt’s drive to improve safety in the health service, following the infamous failures of patient care at Stafford hospital between January 2005 and March 2009. Hunt says that it will bring about a “transformational change” in the NHS, helping it to learn from mistakes.

But the independent service, which began operating on 1 April 2017, has faced opposition to its approach, based on similar systems in the aviation industry. For instance, the charity Action against Medical Accidents has challenged the HSIB for prioritising a ‘safe space’ for healthcare professionals rather than focusing on openness with patients.

Similarly, the case of Hadiza Bawa-Garba in February 2018 — a paediatrician prosecuted and struck off the medical register after the death of a young boy under her care — has highlighted deep-seated concerns in the medical profession about the consequences of being honest about failures in healthcare. As such, there is evidence that a similar fear stops pharmacists from reporting errors.

So, can the HSIB make a difference? A year after its fruition, The Pharmaceutical Journal caught up with Tracey Herlihey, head of safety intelligence at the HSIB, to find out more about its approach.

What is the Healthcare Safety Investigation Branch (HSIB) and what does it do? 

Our organisation was established to investigate and learn from serious and systemic patient safety incidents. Look at how local investigations are conducted now: they are rarely able to capture wider systemic influences contributing to major failures of care. We want to use knowledge gained from our investigations to make recommendations for building a safer healthcare system.

The HSIB engages a great deal with frontline staff

The HSIB talks to patients, healthcare professionals, regulatory bodies, royal colleges, training bodies, the medicine regulator, NHS England, and so on — it’s a real spread. And we engage a great deal with frontline staff.

We’re made up of experienced investigators, from healthcare but also from other industries, such as aviation and the military. Many of us have patient safety backgrounds, but mine is in human factors — a field that’s gaining momentum in healthcare right now — which considers how systems are designed to help us interact with them and do the right thing. It’s one of the main focuses of our investigations.

We carry out our investigations with a ‘just culture’ approach, which, I must clarify, is not the same as ‘no blame’. The just culture, we think, gives the right balance between no blame and accountability. It means not punishing people for making honest mistakes — and from my background in human factors, we know that humans will always make mistakes — but it also means that people will be held to account for wilful, dangerous or reckless acts. We don’t expect to see this kind of behaviour often, but we have mechanisms in place for involving regulators, and others, if we need to.

You have been challenged on your ‘safe space’ approach — is it the right one?  

There are two things here: we have just culture, but we also have what we call ‘safe space’. 

So, just culture — colleagues who have moved over from aviation show us that just culture is really the one approach that offers us the transparency we need during our investigations. It allows us to really learn from these incidents and improve NHS culture, which is one of blame. To us, this is a misunderstanding of the nature of human error. This can lead to doctors, nurses, pharmacists and others facing prosecution — Bawa-Garba’s case being a recent one. The Department of Health and Social Care has recognised the ill effects that a blame culture can have, and we’re hopeful their work will lead to a more sensible approach to these cases. 

There is some contention around the phrase ‘safe space’. What we’re really talking about here is the protection of sensitive safety information; it’s an opportunity for people to provide us with frank information, and they know that we will take only the relevant parts to guide us in our learning.

Have any investigative bodies used this approach before? 

The ‘safe space’ approach is already used in other industries, such as in aviation. Our chief investigator, Keith Conradi, previously led the Air Accidents Investigation Branch, and it worked well there. There are things like safe space in healthcare in different areas around the world, but here, safe space currently sits only within the HSIB.

We’re hoping independence will enable us to offer those involved in our investigations a degree of legal protection over statements they make

A draft bill to set out the HSIB’s independence was recently laid — what does this mean for you? 

We’re hoping the legislation will give us the same level of autonomy in healthcare as our counterparts in aviation. It will make us an independent ‘arm’s length’ body, and we will be able direct our recommendations to national bodies and regulators. We’re hoping it will enable us to offer those involved in our investigations a similar degree of legal protection over statements they make. We want to reassure clinicians who may be reluctant to speak up without this protection.

What has the HSIB achieved and learned in its first year? 

Since April 2017, we have launched nine full investigations in areas ranging from mental health care provision to the administration of medication. The investigations are at different stages, and we’ve published an interim bulletin for each, providing back story and outlining where we expect to take the investigation. We hope to publish our first full report of an investigation in the summer. Some are at the stage where we’re working with those to whom the recommendations will be made, to ensure they don’t come as a surprise and can make change happen.

We’re a learning organisation and we’re new, so we’ve done a lot of internal learning over the past year. We are trying to get the word out about who we are and what we do, and let people know that they can trust us. We’re also learning how best to select investigations that will give us the greatest opportunity to learn.

How do you decide which cases to investigate and what happens to those you are unable to? 

Many of the issues we’re exploring are already widely known. Reporting systems, such as the National Reporting and Learning System, give us a good picture of what’s going on, and we can use them to inform an investigation’s focus. We’ll pick an event that we think is representative of systemic issues. People may refer to us, but we also ask individual trusts if they are happy to work with us on a particular incident for system-wide learning. 

We consider systemic risk. Does the incident happen in trusts across the country? Does it happen again and again, and across different types of care setting?

All cases are assessed against three criteria: outcome/impact, systemic risk, and learning potential. 

We look at the impact of the particular safety issue on all people involved, on the quality of service offered by the NHS, and on public confidence in the NHS. We also consider systemic risk — how widespread the issue is. Does the incident happen in trusts across the country? Does it happen again and again, and across different types of care setting?

Lastly, we consider learning potential. Has work has already been done on the issue, or would we be reinventing the wheel? We take on stuff that we think — in our position at HSIB — could result in real improvements to systems and practice.

We follow up each case that we’re unable to investigate with a letter to explain why and to direct people to more appropriate organisations.

How can healthcare professionals voice their concerns about a health safety incident? Do they have anything to fear? 

They can request an investigation with HSIB by filling in the form on our website.

Organisations we work with remain anonymous, unless they want to say they are working with us on a particular investigation

We are new, so people are still a little wary about us, which is understandable. But there isn’t anything to fear. Organisations we work with remain anonymous, unless they want to say they are working with us on a particular investigation. When we work with an organisation, it’s not because we see an issue with that organisation, or the people involved in a specific incident. We’re working with it because we see similar things happening across the NHS, and we think we can extract a great deal of system-wide learning. We don’t expect to make recommendations to specific trusts; instead we make recommendations to regulators, royal colleges and other professional bodies.

Do you seek insight from pharmacists during your investigations?

Absolutely. We’ve engaged with pharmacists on the wrong route administration case, which involved midazolam being drawn up into a purple syringe (meant for oral use only). It was later decanted into a regular syringe and injected into a patient. We spoke to medication safety officers and chief pharmacists to get an understanding of the syringes and the potential of Scan4Safety — a barcode technology that traces NHS patients, and the treatments and supply involved in their care, and their effectiveness — for avoiding this issue.

We see ourselves as investigation experts, but our recommendations will be directed at people who are experts in their field and can bring about change — if a case involves medication, we need frontline expertise from those who know a lot more about it than we do. I’m sure we’ll involve pharmacists more heavily as we take on new cases; we need those multiple perspectives.

In 2016, health secretary Jeremy Hunt said we need to “make the need for whistleblowing and secrecy a thing of the past” — how far have we come and how far away is an NHS that learns, not blames? 

There’s still a blame culture in the NHS, and Hunt’s recognition of this is a move in the right direction. But we’re getting there.

NHS Improvement has opened a consultation on how patient safety investigations should be conducted in the future. That’s going to be important in how we extract learning from the investigations done at the local level, the impact of blame, and developing a just culture for these investigations.

Individual trusts are also starting their own initiatives. I recently came across a video tweeted by Mersey Care NHS Foundation Trust, which highlighted the work they’ve done with human factors professor Sidney Dekker on transferring their culture to one that is “just and learning”. They’re making good progress, and a lot is going on across the NHS, but there are still improvements to be made. The HSIB is here, but we’re just one part of the puzzle.

Last updated
The Pharmaceutical Journal, PJ, May 2018, Vol 300, No 7913;300(7913):DOI:10.1211/PJ.2018.20204779

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