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Practice comment

Organisational culture is the key to improving patient safety

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With Patient Safety First Week taking place this week, Cheryl Crocker argues that a persistent blame culture is in danger of stifling improvements in patient safety

 

It is no secret that many feel a blame culture exists in today’s NHS. With such feeling, it is understandable there would be some worry among nurses about whether to report patient safety incidents. And indeed, the number of incidents of harm or potential harm is thought to be under reported. I believe the persistent failure to eliminate the blame culture that exists in most NHS organisations is a major reason for this.

A number of reports have recommended the NHS develop a more open culture, in which errors or service failures can be reported and discussed, often referred to as a “no blame culture”. The House of Commons Health Committee (2009) reiterated the need for change, but to a more realistic “fair blame culture” rather than a “no blame” one. The term “no blame culture” has been widely used in the past but is rather inaccurate and unhelpful, as in cases of malicious or inept conduct any blame attached to an individual would clearly be appropriate.

Research into safety in healthcare has shown that the best people sometimes make the worst mistakes and that errors fall into recurrent patterns regardless of those involved. We also know that harm events are far more likely to result from systems failure than failure of individuals. To help improve patient safety, trusts across England are focusing on improving systems, to make it easy to do the right thing and hard to do the wrong thing.

Increasingly, the response to an incident in the NHS is to identify the underlying causes, promoting learning that could prevent future harm events, rather than to blame the individual. However, perceptions among nursing and other non medical staff is that they risk suspicion if they report a serious incident and junior doctors believe the current incident reporting system still focuses on apportioning blame.

Nursing leaders need to be open about incidents to encourage improvements, and must normalise the need to improve by making it a part of ward life. Plenty of support on communicating changes and implementing evidence based practices is available through initiatives such as Patient Safety First, to which 94% of acute trusts are signed up.

“Nurses must be part of the safety agenda and be empowered to act”

Another way of developing a fair blame culture is to first benchmark the organisation’s culture. A number of safety culture measurements are available and are useful in helping organisations develop an action plan to enable them to move forward. This can also be done at ward or individual level. However, leaders at all levels need help to develop their role and responsibilities in leading a safety agenda. The Patient Safety First leadership intervention provides a number of suggestions.

One way is to introduce executive safety walkrounds. Leaders need to interact with frontline staff to understand what the safety issues are. Nurses must be part of the safety agenda and be empowered to act. The safety walkrounds will involve feeding back to wards and involving nurses in action-planning around the points raised by staff. For the organisational culture to change, all staff need to embrace the values and behaviour of the organisation, and help each other in doing so.

When leaders begin to change their responses to mistakes and failure, asking what happened instead of who made the error, the culture within healthcare organisations will begin to change and patient safety will be improved.

CHERYL CROCKER is a member of the Patient Safety First core team, and currently fellow, NHS Institute for Innovation and Improvement, seconded from Nottingham University Hospitals Trust where she is consultant nurse.

 

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