Sixteen years after an Organisation with a Memory was published, Jonathan Hazan Director at Datix, takes a closer look at what has been achieved in that time and what still needs to be done in order to truly learn lessons from incidents and serious events across the NHS.
Sir Liam Donaldson’s report “An organisation with a memory” was published in 2000. The report suggested a number of key areas in which the NHS needed to modernise its approach to learning from failure. These included a call for better systems for reporting and analysis, a wider appreciation of the value of a system approach to learning from error and a more open culture that encourages reporting and discussion when things go wrong. However, how much progress has there really been made in the last sixteen years, in terms of sharing information and learning from incidents and serious events in the NHS?
Despite excellent initiatives such as the establishment of the National Reporting and Learning System (NRLS) and the National Patient Safety Alert System (NPSAS), which has been operational since 2003, evidence still suggests that shortcomings remain in terms of the response to adverse events within the NHS.
A recent review of 150 cases referred to the Parliamentary and Health Service Ombudsman (PHSO) found that more than one third of NHS investigations relating to allegations of avoidable harm or death were inadequate and failed to identify when something had gone wrong. So what still needs to be done to ensure the best intentions of the last 16 years are implemented? What is standing in the way of truly achieving an organisation with a memory, to the benefit of NHS service users and those working within the organisation?
It all comes down to people, leadership and trust.
The government has recently announced a range of measures aimed at supporting the development of an open learning culture. These included the establishment of a National Freedom of Speak Up Guardian and a new national Healthcare Safety Investigation Branch (HSIB). In addition a new medical examiners system, a recommendation dating back to the Shipman report (2003), will be rolled out across the NHS by April 2018. However, all of these valiant initiatives are dependent on people for success. People working in healthcare do not turn up for work with the intention of doing harm to patients, however, modern medicine is complicated and often dangerous. Shortcuts are taken, workarounds used and conclusions reached, before all the evidence is available. Therefore, healthcare becomes a risky business and mistakes happen.
For example a report commissioned by the Department of Health in late 2014 said that 5-8% of unplanned hospital admissions were due to improper use of medication. The report went on to state that at least £1bn, if not £2.5bn, was wasted by the NHS on preventable errors, many of which also related to the improper use of medication.
However, to learn from mistakes everyone needs to feel confident of a supportive culture often referred to as a “Just Culture” where staff can report and openly discuss errors knowing that they will not be blamed unfairly. As Professor Don Berwick said in his 2013 report – healthcare organisations must choose between safety or fear; both conditions cannot exist side by side.
My next article will explore what a just culture really looks like and what needs to be done to ensure that the NHS is an organisation with a memory, rather than an organisation that continues to miss opportunities to learn and improve.