CONTENTS

politics first | Corridors
Turning healthcare systems
into learning organisations
Jeremy Hunt, Secretary of State for Health and Conservative MP
for South West Surrey
Every year, an estimated one million patients die in
hospitals across the world because of avoidable clinical
mistakes. It is difficult to confirm the exact number
because of the variability in reporting standards but, if
it is of this scale, avoidable clinical mistakes sit along
hypertensive heart disease and road deaths as one of
the top causes of death in the world today.
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In the United States, they estimate it at
up to 100,000 preventable deaths annually
and, in England, the Hogan, Darzi and Black
analysis says that 3.6 per cent of hospital
deaths have a 50 per cent or more chance
of being avoidable – that is 150 avoidable
deaths every week. Holland and New Zealand
make similar estimates.
In 1990, a bright 24-year-old medical
school graduate started his first job in
medicine. He was a pre-reg house officer
looking forward to a glowing career in
surgery. In his first month, he was attending
to a 16-year-old boy undergoing palliative
chemotherapy. The boy needed two injections,
one intravenously and one by lumbar puncture
into the spine. The intravenous drug was
highly toxic – indeed, fatal – if administered to
the spine. But it arrived on the ward in a nearly
identical syringe to the other injection. Both
syringes were handed to the young doctor for
the lumbar puncture procedure and both were
injected into the patient’s spine. As soon as
the doctor realised what had happened, frantic
efforts were made to flush out the toxic drug
but to no avail and, tragically, the patient died
a week later. So what happened next?
You might think the most important priority
would be to learn from what went wrong and
make sure the mistake was never repeated.
But, instead, the doctor was prosecuted
and convicted for manslaughter. He and a
colleague were given suspended jail terms.
The convictions were, eventually, overturned
at the Court of Appeal. But the real crime
was missed; as the legal process rumbled
on, exactly the same error was made in
another NHS hospital and another patient died
because our system was more interested in
blaming than learning.
The blame culture does not just create fear
for doctors. It causes heartbreak for patients
and their families, as I discovered when I met
the parents of three-year-old Jonnie Meek who
tragically died unexpectedly in hospital in
2014. His parents found their grief at losing
Jonnie compounded by the immense difficulty
in establishing what exactly happened. But it
should not need an inquest to find out the
truth. Instead, we need to ask what is blocking
the development of the supportive, learning,
culture we need to make our hospitals as safe
as they should be.
In England, we have made much progress
in improving our safety culture following
the Francis Report into the tragedy of Mid
Staffs. According to the Heath Foundation,
the proportion of patients being harmed
in the NHS has dropped by over one-third
(34 per cent) in the last three years. MRSA
bloodstream infections have fallen by over half
in the last five years. The law has changed,
placing on all hospital trusts a statutory duty
of candour to patients and their families when
things go wrong. The government was elected
on a firm commitment to make NHS care
safer across all seven days of the week and
we are making good progress. But if we are to
complete this journey we have to change from
a blame culture to a learning culture.
Matthew Syed, in his book Black Box
Thinking, explains how that same blame
culture used to exist in the airline industry.
He tells the tragic story of United Airlines
flight 173, where 10 people died in a crash in
December 1978. The pilot, Captain Malburn
McBroom, was trying to rectify a potentially
dangerous problem with the landing gear but
failed to notice that the plane was dangerously
low on fuel. When he was forced to crash land,
he did so with extraordinary skill, saving the
lives of 150 passengers. But because of his
mistake - not noticing the low fuel levels - he
got tied up in a seven year long court case,
came close to suicide, lost his pilot’s licence
and, ultimately, died a broken man.
But that tragedy had a surprisingly positive
ending. Because it was the moment the airline
industry realised that, if it was going to reduce
airline fatalities, it needed to change its culture.
They realised that ‘human factors’, rather than
technical or equipment failure, had been at the
heart of the problem. Anyone could have failed to
notice low fuel levels when they were trying to fix
the landing gear. Why did not other crew members
spot the problem and speak out? The issue was
not that particular person, but what could have
happened to any person in the same situation.
As a result, airlines transformed their training
programmes. They mandated reforms that required
pilots to attend group sessions with engineers
and attendants to discuss communication,
teamwork and workload management. Captains
were required to encourage feedback, and crew
members to speak up boldly.