The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [122]
Organizational culture is difficult to define and assess (Davies et al. 2000) but there is wide agreement that one of the key impediments to openness in NHS institutions is fear of professionally harmful consequences such as loss of job and/or reputation and litigation (Meurier 2000). Reason (2006) has argued that the source of such fears lies in the myth that errors are the exception rather than the norm in healthcare and must therefore be the fault of flawed individuals.
Fear of blame can lead professionals to draw back from openness and instead take refuge behind professional lines. For example, an in-depth study by Shaw et al. 2007 revealed that frontline nurses felt unfairly targeted when patient incidents occurred. As a result, they became less open to new ideas of treatment and to participating confidently in multidisciplinary practice.
Approaches that refocus attention on wider issues and underlying factors of patient incidents are thought to be more helpful because they avoid prior assumption of personal blame, promote open reporting and stimulate learning from mistakes (Vincent 2006). The Being Open policy (NPSA 2005) requires all NHS organizations to establish an infrastructure which facilitates openness between staff, patients and carers following an incident. Research confirms that patients would welcome prompt disclosure and an apology when incidents occur (Carthey 2005).
Developing a ‘no blame’ culture within the NHS has been key in recent developments in patient safety, though dilemmas still remain for many nurses when working with staff who have been involved in patient safety incidents. Studies have shown that the best way of reducing error rates and preventing harm is to target failures in systems, and involve staff in reducing risk and participating in learning from near misses rather than taking actions against individual members of staff (Macrea 2008).
The National Reporting and Learning Service of the NPSA provides examples of frequently reported patient safety incidents and then suggests ways to redesign systems, increase learning and reduce risk. Recently published examples include reducing the risk of harm from chest drains and from prescribing and administering controlled drugs (NPSA 2010). Dr Lucian Leape from the Harvard School of Public Health suggests that individuals and organizations confront two myths concerning patient safety.
The perfection myth: if people try hard enough, they will not make any errors.
The punishment myth: if we punish people when they make errors, they will make fewer of them.
The National Patient Safety Agency has a key role both in producing guidance and offering support to professionals, and in the analysis and benchmarking of safety data across healthcare services to identify trends and lessons learned (NPSA 2009). It recognizes that healthcare will always involve risks, but that by adopting a culture of openness and transparency, and tackling the root causes of patient safety incidents, risks can be reduced.
The National Patient Safety Agency (NPSA)
The NPSA was established in 2001. Its two main aims were, firstly, to identify trends and patterns in patient safety problems through its National Reporting and Learning System (NRLS) and secondly, to support staff at the local level to report incidents with a view to ensuring a high national profile for improving patient safety. Subsequently, the agency has undergone several significant changes. In 2005, its remit was expanded to cover safety aspects of hospital design, food and cleanliness, safety issues in research and support for local performance concerns.
The launch of the Never Events Policy for England in March 2009 (NPSA 2009) is the most recent attempt to set patient safety targets. It defines eight core events considered absolutely preventable, including wrong site surgery, inpatient suicide using non-collapsible rails, and wrong route administration of chemotherapy. The never events framework lists highly specific and selected risks but is intended to act as a spur to the risk and patient