Reliability of Clinical Systems in the British NHS
Some healthcare processes, such as the administration of radiotherapy, achieve very high levels of reliability. Other processes are haphazard to say the least. Burnett and colleagues (2012) examined the reliability of four clinical systems in the NHS: clinical information in surgical outpatient clinics, prescribing for hospital inpatients, equipment in theatres, and insertion of peripheral intravenous lines. Reliability was defined as 100 % fault free operation when, for example, every patient had the required information available at the time of their appointment.
Reliability was found to be between 81 and 87 % for the systems studied, with significant variation between organisations for some systems; the clinical systems therefore failed on 13–19 % of occasions. This implies, if these findings are typical, that in an English hospital: doctors are coping with missing clinical information in three of every 20 outpatient appointments and there is missing or faulty equipment in one of seven operations performed. In each case where measured, about 20 % of reliability failures were associated with a potential risk of harm. On this basis it is hardly surprising that patient safety is routinely compromised in NHS hospitals and that clinical staff come to accept poor reliability as part of everyday life.
Following the Rules: Reliability of Human Behaviour
Delivering safe, high quality care is an interplay between disciplined, regulated behaviour and necessary adaptation and flexibility. Rules and procedures are never a complete solution to safety and sometimes it is necessary to depart from standard procedures in the pursuit of safety. However, protocols for routine tasks are standardised and specified precisely because those tasks are essential to safe, high quality care.
Protocols of this kind are equivalent to the safety rules of other industries – defined ways of behaving when carrying out safety-critical tasks (Hale and Swuste 1998). Examples in healthcare include: checking equipment, washing your hands, not prescribing dangerous drugs when you are not authorised to, following the procedures when giving intravenous drugs and routinely checking the identity of a patient. Such standard routines and procedures are the bedrock of a safe organisation, but there is ample evidence that such rules are routinely ignored:
• Hand washing. Contamination through hand contact is a major source and hand hygiene a major weapon in the fight against infection (Burke 2003). Studies have found that average levels of compliance, before major campaigns were instituted, have varied from 16 to 81 % (Pittet et al. 2004).
• Intravenous drug administration. Studies have found that over half involve an error, either in the preparation of the drug or its administration. Typical errors were preparing the wrong dose or selecting the wrong solvent (Taxis and Barber 2003).
• Prophylaxis against infection and embolism. Only 55 % of surgical patients receive antimicrobial prophylaxis (Bratzler et al. 2005) and only 58 % of those at risk of venous thromboembolism receive the recommended preventive treatment (Cohen et al. 2008).
The causes of departure from standards are many. In some settings the working environment is reasonably calm and orderly so staff are able to follow clear protocols and abide by core standards. In other settings however the pressures are great, the environment noisy and chaotic and staff are essentially just trying to do the best they can in the circumstances. In any systems there are pressures for greater productivity, less use of resources and occasions where missing or broken equipment forces adaptations and short cuts; add to this that we all, occasionally or frequently, are in a rush to get home, get on to the next case, tired or stressed and apt to cut corners. Standards may be unrealistic or too complex; staff may not be sufficiently skilled or have not received the necessary training. Working in such conditions is an everyday occurrence for many clinicians and acts as a constant reminder of the care they would like to give and the reality of the care they are able to provide. Over time however these departures from standards can become increasingly tolerated and eventually invisible (Box 2.2).
Box 2.2 External Pressures and Gradual Migration to the Boundary of Safety
Occasional lapses can become more tolerated over time and systems can become gradually more degraded and eventually dangerous. The phrase 'illegal normal' captures the day-to-day reality of many systems in which deviations from standard procedures (the illegal) are widespread but occasion no particular alarm (they become normal). The concept of routine violations is not part of the thinking of managers and regulators; in truth it is a very uncomfortable realisation that much of the time systems, whether healthcare, transport or industry, operate in an 'illegal-normal' zone. The system continues in this state because the violations have considerable benefits, both for the individuals concerned and for managers who may tolerate them, or even encourage them, in the drive to meet productivity standards.
Over time these violations can become more frequent and more severe so that the whole system 'migrates' to the boundaries of safety. Violations are now routine and so common as to be almost invisible to both workers and managers. The organisation has now become accustomed to operating at the margins of safety. At this stage, any further deviance may easily result in patient harm, and would generally be considered as negligent or reckless conduct (Amalberti et al. 2006).