Characteristics of a safe Service

Human Error and Bad Outcomes

No one comes to work to do a bad job.

When something goes wrong however it is all too easy to put it down to human error or a “Bad Apple” and find someone to blame, then put up more posters and introduce sanctions in the hope that this will change people’s behaviour. Without thinking we assume people are the problem and that they need to change their attitude. Such thinking however has proven ill-founded and no matter how many posters are put up the problem persists.

A more considered approach accepts human error is not the cause of trouble and that the error is a consequence, effect or symptom of deeper trouble inside the undertaking. When something bad happens, we must look beyond the people, to the working conditions prevailing when the bad outcome occurs. Management or others in the organisation may have helped create those bad conditions.  Leave those conditions unchanged and the same bad outcome may happen again – no matter how many sanctions you impose, or safety attitude campaign are launched. (See further “The Field Guide to Understanding Human Error” Sidney Dekker).

Recent NHS failures

Multiple avoidable deaths in NHS maternity units resulted in the Sec. of State Jeremy Hunt commissioning an independent review by former midwife Donna Ockenden. Her draft report was leaked recently.  Jeremy Hunt in The Telegraph (12 Feb 2020) referring to the leaked report describes a:-

“longstanding culture at the Trust that is toxic to improvement effort’; an ongoing failure to listen to bereaved parents during investigations and learn lessons; …..It’s clear that transparency about poor care is not enough on its own. Maternity units up and down the country need extra support both in terms of staffing levels and training to make sure they can adopt best the best practice that is common in many hospitals. Most of all we need to tackle an insidious blame culture that still means that if a doctor, midwife or nurse makes a mistake – sometimes with tragic consequences – they are able to talk about it openly.”

A blame culture and a refusal to learn lessons clearly fits in with the simplistic view that bad outcomes are due to human error or “Bad Apples”. Lessons can only be learnt, and improvements made if an organisation sees human error as the beginning of the review and accepts the cause of the problem is likely to be much deeper in the organisation or working conditions themselves.

Reducing Risk of Errors in Homecare

Unlike aeroplanes and other critical equipment, when running a service performed by people, there are no fail safe systems that can reduce the risk of a bad outcome to zero.  Instead we have to take every step and do everything we reasonably can to prevent a bad outcome.  This includes making sure we have the right culture, processes and systems.

The home care sector is regulated by the Care Quality Commission (CQC) who provide detailed guidelines and regulations followed up by regular in-depth inspections.

Our safety related processes and systems include a robust recruitment process, enhanced DBS checks, comprehensive training and e-learning, shadowing, spot checks, one-to-one supervision, team meetings, refresher training, daily visits logs and medication charts. This is supported by IT systems allowing amongst other things, remote log-in and alerts when carers are delayed.  Detailed Support Plans for each client include risk assessments for known risks, which are reviewed regularly. Any incidents or bad outcomes are recorded and reviewed. Lessons are learnt and where necessary action plans put in place to make changes.

In the event of a bad outcome we consider three simple things: feasibility, usability, reliability:-

1.        Feasible – Is what we are asking our carers to do feasible? Can it be done in the time allotted? Do we have enough carers to fulfil all the visits? Is the individual carer the right people in the first place, suitably skilled and trained with all the information he or she needs to do the job?

2.        Usability – are our procedures workable? Are they written in consultation with those we need to follow them? Is the language appropriate for our carers?  Remember it is easier to write for The Times than it is for The Sun. Is the equipment needed/required/provided suitable and optimised for the task?

3.        Reliability – the tough one – What can go wrong? What controls and barriers do we have in place to prevent error? How robust are these? How can they be defeated wittingly and unwittingly? What are the performance shaping factors involved in doing the job e.g. time pressure, shift patterns, fatigue, environment, etc?

In home care, there is a high risk that too much time-pressure on carers will to lead to errors. As a consequence, we do not do any visits of less than hour. If we feel an hour is insufficient to provide a safe service, then we will discuss this with the client and their next of kin to arrange longer visits, thus making the service safer.

Key Lines of Enquiry

The CQC used Key Lines of Enquiry to assess the performance of the organisations it regulates. It also publishes guidance on the characteristics of what a Good or Outstanding service should demonstrate. The first Key Lines of Enquiry is, “Is the Service Safe”. Key questions asked are:-

1.   How are safety and safeguarding systems/processes and practices developed implemented and communicated to staff? How are they monitored and improved?

2.   How are clients protected from discrimination?

3.   How is safety promoted in the recruitment practice?

4.   What ongoing checks on staff are made?

5.   Do staff understand their safeguarding responsibilities?

6.   How are standards of cleanliness and hygiene maintained?

7.   Are comprehensive risk assessments carried out for clients? Are risks managed positively?

8.   How do staff identify and respond to changing risks to clients e.g. deteriorating health?

9.   Is all information needed to deliver safe care available to carers in a timely and accessible way?

10. How does the service make sure that clients receive their medicines as intended, and is this recorded appropriately?

11. Are clients’ medicines regularly reviewed including the use of ‘when required’ medicines?

12. How does the service make sure that clients’ behaviour is not controlled by excessive or inappropriate use of medicines?

13. How does safety performance compare with other similar services?

14. How well is safety monitored using information from a range of sources (including performance against safety goals where appropriate)?

15. Do staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally?

16. What are the arrangements for reviewing and investigating safety and safeguarding incidents and events? Are all relevant staff, services, partner organisations and clients who use services involved in reviews and investigations?

17. How well is the learning from lessons shared to make sure that action is taken to improve safety? Do staff participate in and learn from reviews and investigations by other services and organisations?