The unhappiest places that I have ever worked in were those in which a culture of blame operated. The boss would emerge from his or her office, facial features set in the "angry" mode, demanding to know why a competitor had a story or an interviewee that we didn't. Or there had been a complaint and the immediate assumption was that someone must be at fault. The next tier down would, in their turn, cast about for the person who had failed to make the crucial call, and the psychology of blame and excuse would skip from person to person like head-lice. You got the blame declension: they were incompetent, he was careless, you were unlucky and I did the very best that I could given the lack of resources that were available to me. Most human beings want responsibility – there are few who want blame.
So, perversely, it's bloody good news that a new study has shown so many balls-ups in the NHS, a few of them fatal. It's great because of the way the study was conducted, because of who participated in it, and – above all – because of the message it sends out to producers and consumers of the NHS, which is: "Tell us." All we have to do is to read the results carefully and to try to draw the right conclusions from them. And if I tell you that such a feat is beyond some in my profession, well you won't be surprised.
The study itself, conducted by the National Patient Safety Agency (NPSA), a body created only last August, is a detailed survey of what are called "adverse incidents", as reported by staff in 28 NHS hospitals over a six-month period. In that time 24,500 such incidents were logged, ranging from the most trivial error of bandaging to death being caused by the mistaken administering of drugs. There were some 300 incidents apparently involving errors made during childbirth. This is – remarkably – the first time that NHS employees have themselves been requested to report such incidents.
Already, despite the provisional nature of the study (which I will return to), the exercise has led to a possibly life-saving observation. Mistaken use of potassium chloride, which is administered to supplement the levels of the metal in potassium-deficient patients, has, it is suggested, killed three patients in the study hospitals over the half-year period alone. So, as a result, the NSPA is about to issue a patient safety alert – its first – recommending tighter procedures for the labelling of potassium chloride and advising staff about its use. The immediate response of NHS staff has been wholly positive.
A miracle? Not a bit of it. I was struck this week by the courageous interview given by Phil Hammond, the presenter of the BBC series Trust Me I'm a Doctor. In the interview Hammond tells how, as a young doctor, he nearly killed a woman patient with potassium chloride.
It was 3am, and he was working on a locum shift, when he was called to see the woman, who needed a small amount of potassium to be given in a saline drip. But the bottles, the saline and the potassium looked nearly identical. Hammond hooked up the potassium by mistake.
"If the drip had been in properly," Hammond said, "I would have killed her. Fortunately I was so incompetent that I hadn't even done that properly." Even so the potassium that did get to the area around the needle caused the patient a great deal of pain. Then, revealed Hammond, "I realised straight away, but I didn't admit what had happened, I made some fatuous comment that she must be allergic to saline".
So what went wrong? Hammond was tired, he said, adding: "I was too naive and not brave enough to ask for help." The incident was never reported, and, indeed, there wasn't really anybody to report the incident to. Doctors in those days, he said, did not own up to their mistakes. "You just burn the notes, bury the X-rays and push it under the carpet." There was (and presumably still is) a lot of it about.
At one level we can decide to be terribly shocked over all this, since we all harbour fears of going into hospital for something routine, and coming out on a gurney. Partly as an extrapolation from this work and partly because of other types of study, England's Chief Medical Officer, Professor Sir Liam Donaldson, estimates that one in 10 hospital patients may suffer from an adverse incident (this figure, incidentally, was magically doubled in yesterday's Daily Mail.)
I have certainly seen one minor incident at firsthand last year, when an attempt to put a drip in my mother's wrist failed, squirting blood and saline mixture all over the ward.
But being shocked won't help. In the first place, we can all do it. If – as a semi-literate columnist – I confuse the christian name of Bertie Wooster's aunt with that belonging to Oscar Wilde's Lady Bracknell (and I have), no one dies. Still, it's embarrassing, and if I err a lot, it irritates readers. I can, though, be helped to avoid errors like this. A sub-editor or page editor might notice, if they have enough time. Or – even better – I can just be made aware of my dangerous tendency to overestimate the capacity of my own memory.
We won't fess up though, if we think that we'll be blamed. If getting the Wooster aunt wrong was a shouting, suing or sacking offence at The Indy, then the chances are that I would either avoid literary allusions altogether, or – if it all went tits-up – accuse the poor bloody subs of not being sufficiently diligent.
The same is true in spades in a profession where small errors can end up having enormous consequences. The NSPA study and its methodology are therefore of exceptional importance in discovering and helping to reduce the number of adverse incidents.
We only have to look over at the sterile spectacle of the law-and-order debate to see how little good the blaming business does. As with the medical professions, most lawyers do their job within the culture and the rules that were there when they arrived. The NSPA understands this. On its website it says: "identifying and addressing dysfunctional systems is... the key to reducing future risk of harm for many NHS patients and is the ethos behind the new national system for reporting adverse incidents..." The website does not talk about seeking out sloppy docs and giving them the boot. The same goes for briefs.
I do have a caveat in this happy argument. As ever these days, the leaking of the provisional NSPA report led to claims that the Government was seeking to suppress bad news about the NHS. Since the Department of Health set up the NSPA with the specific remit to carry out such a study and publish its findings, this accusation is some way off the mark, as Sir Liam himself has explained. Because this study is so unique and the reporting on which it is based so far from uniform, it was not unreasonable for the authorities to cavil at publishing the raw data. But the story, surely to God (and here, as so often, I cast my eyes towards the editor of the Today programme, Rod Liddle) was what the study told us about the NHS and how to improve things. So Rod, can you get your editorial staff to read something other than the Daily Mail? Myself, I blame that Greg Dyke.Reuse content