Significant events and Swiss cheese

There is a scientific discipline called human factors and ergonomics (HF&E) which recognises the absolute certainty that human beings will make mistakes, and so seeks to design working systems and environments that work around our human nature to reduce the risk of error as far as possible.

Many safety-critical industries like aviation have wholeheartedly adopted HF&E engineering to protect their workforce and service-users from errors. When there is a significant event, the immediate assumption is that there must be a fault somewhere in the system that allowed gaps in the layers of error protection to align and allow a mistake to slip through - rather like the holes in layers of swiss cheese suddenly all lining up (get it?!)

Does any of this sound like what happens in the healthcare system? There is some talk of no-blame investigations and developing a culture of protecting whistleblowers. But in the midst of a locum session, where no induction in practice protocols has been made available, trying to see complex patients in 10 minute appointment slots, dealing with missing results and clinic letters and coping with repeated interruptions for queries from practice staff, it feels like primary care is light years behind being an ideal safe environment.

Many GPs are forced to work under these conditions to their great personal cost in terms of feelings of inadequacy, exhaustion and shame that they are not able to provide better care for their patients, even though the many factors that lead to this enforced underperformance are not directly under their control or responsibility.

This bias of seeking to find fault with individuals – ourselves and others – for wider systemic failings, often extends to our response to significant events.

There are many psychological, emotional, behavioural, logistic and perhaps legal reasons why it is easier to individualise blame for a significant event, and locums may be particularly vulnerable. But this approach misses the point and fails to examine the systemic and environmental factors that came together to contribute to the mistake and so condemns us and our patient to the same error in future.

So if you are involved in a serious safety-related significant event, take a deep breath and think of Swiss cheese.

  • Recognise your own emotional response to the event, be that shame, guilt, fear, anger, loss of confidence. Discuss these with a trusted colleague.
  • Be aware of our tendency to disproportionately allocate blame to individuals, including ourselves, or being made to feel blame by others.
  • Do not allow this to hamper your ability to think beyond the emotional to examine all the contributory factors.
  • Mistakes rarely happen in a vacuum, and you may find that the process of enhanced significant event analysis, developed by NHS Scotland and crafted by NASGP into a series of templates as part of NASGP AppraisalAid, helps take you through this process.

Significant event analysis is not something you carry out in isolation. Ideally you would be involved in significant event analysis with the practice team in question. If this is not possible, going through the event with your GP locum group or chamber is of great value and can lead to real improvements, especially if you decide to changes as a group, thereby multiplying the impact of your significant event learning to others.

The NASGP enhanced significant event template could be your personal record of the event. Feel free to share it with the other people involved. It would be wonderful to spread this de-personalised, systems-based approach to dealing with significant events.

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