Strategy IV: Monitoring, Adaptation and Response

Safety is achieved partly by attempting to reduce errors but also by actively managing the problems and deviations that inevitably occur. Once we accept that errors and failures occur frequently in any system then we see the need to develop methods of monitoring, adapting and responding and recovering from failure. Adapting and responding to problems happens all the time in healthcare and is as relevant to managers as to frontline staff. Managers in particularly are constantly 'firefighting' and resolving problems, but this tends to be done on an ad hoc individual basis. The question we address here is whether these often improvised adaptations can evolve to become formal safety strategies in the sense of actively building such capacity into healthcare systems. Ideally senior clinicians and managers would maintain safety at a good level by playing on a palette of known and practiced organisational and cultural adjustments.

Adapting and responding is much more important in deep sea fishing than on an assembly line but all work requires this capacity to some degree. Being on the lookout for problems, adapting and working around difficulties is part and parcel of all jobs. In high risk industries such as healthcare the pattern is the same but the stakes are much higher and the capacity for rapid response and recovery may literally be a matter of life and death. This family of interventions is paradoxically the most used in daily work in healthcare but not properly developed as a strategic reality in patient safety.

The broad capacity of adapting and responding has been discussed extensively in the safety literature and made the cornerstone of some approaches to safety such as resilience engineering (Hollnagel et al. 2007). The term resilience is used in very different ways (Macrae 2014), sometimes very broadly in an attempt to describe and articulate the qualities of a safe organisation and sometimes in a more restricted sense of a capacity to adapt and recover from extreme or unusual circumstances. We believe that resilience is an important concept that needs serious consideration and further research and exploration in practice. However to avoid potential confusion we use the more everyday terms of monitoring, adaptation and recovery to denote occasions where or hazards or failures have been detected and are being actively managed or corrected.

We will describe a number of interventions associated with this approach in the following chapters and will just give some brief examples here (Table 6.4). An emphasis on the open discussion of error and system failures by senior leaders is enormously important in fostering a willingness to speak up and intervene if a patient is at risk. Clinical teams use many adaptive mechanisms, both formal and informal, to manage safety on a day to day basis. Anaesthetists for instance have a standard repertoire of prepared emergency routines which are called upon in certain situations. These routines are only seldom used and are deliberately honed and standardised so that they can be adhered to at times of considerable stress. At an organisational level we could see preparations for a possible infection outbreak in a similar way (Zingg et al. 2015). Briefings and debriefings can be used by ward staff, operating theatre teams and healthcare managers to monitor day to day threats to safety. For example, briefings carried out by operating theatre teams provide an opportunity to identify and resolve equipment, staffing, theatre list order issues before a case starts. Debriefings carried out at the end of the theatre list support reflective learning on what went well and what could be done better tomorrow.

Table 6.4 Improve capacity for monitoring, adaptation and response

Increasingly, briefings and debriefings are being introduced in other healthcare domains such as safeguarding adults and mental health teams (Vincent et al. 2013).