Safety expert says ‘linear’ approach is not working

By Juliette Astrup on 04 October 2018 RCM Annual Conference Safety NHS

Leading safety expert Dr Suzette Woodward delivered a compelling message to delegates from the RCM conference stage in Manchester, telling them ‘we need to take the blame out of failure.’

Suzette, national clinical director of Sign up to Safety, a national NHS patient safety campaign, shared her powerful insights on why the current ‘linear’ approach to safety is not working.

‘We all know that the little decisions we made yesterday and the decisions we’ll make tomorrow might lead to success. But those same decisions, depending on the circumstances, on the patient you’re confronted with, the people you’re working with, might actually lead to failure. When those same decisions that led to success lead to failure – what do we do? We judge every single one of those people on the failure.’

She questions ‘why are we only looking at where it goes wrong?’ Referring to the global body of research, which show in healthcare ‘around about 10% of things go wrong and lead to harm’ she asked: ‘What about that 90%?’

‘Safety for me is about thinking about every single day, every single moment we help each other work safely. To do that you have to understand when things go wrong, when things go ok, and when things go amazingly – in order to learn that you have to look at things differently.’

So rather than pursuing blame it means ‘relentlessly pursuing knowledge and understanding what we do everyday that keeps us working safely. 0% harm is not a possibility.’

Suzette also spoke about her own personal experience as a paediatric nurse, when she administered 10x the correct dose of medication during a nightshift, and her own urged to interrogate and understand what went wrong.

She urged delegates ‘not to judge each other’ adding: ‘Why do we define ourselves by one mistake one error, why do we define others, why do we end people’s careers because of it?’ She adds: ‘We need to take the blame out of failure. Pursuing justice will always produce truths and lies, losers and winners, adversaries and supporters. By treating error as a crime, we ensure that there will always be losers, whatever the outcome.’

She spoke about the impact of being kind: ‘Not just because it’s the nice thing to do. The evidence base shows it affects performance, team working, your ability to be a leader, your ability to care for the people you care for.’

Especially the need to be kind to those who have made a mistake. ‘It wasn’t their fault. They didn’t intend to harm anybody,’ she said.

She added: ‘Never forget how powerful it is to simply say thank you – but you’ve got to mean it. Tell people in detail about how brilliant they are because the more you do that the more they will want to repeat that feeling you make them feel – that feeling of being proud, appreciated respected.’