In an empty theatre no patient is being harmed. No errors are being made. Nobody at the sharp end is making holes in the cheese of harm prevention. In the patient-less theatre nobody is sitting in the hot seat, frantically flicking through the field guide to understanding human error while hoping for a heroic recovery to restore patient safety.
This is a fundamental aspect of patient safety in surgery; if we carried out no surgery, no patient would come to harm due to surgery. As we all appreciate, this is not going to happen in the foreseeable future. We will continue to operate and patients will continue to be harmed due to human error in its various shapes and guises.
We must look then to reducing or minimizing harm, bringing the risk of harm down to as low as reasonably practicable (ALARP). We could classify the modifiers of this risk into internal and external (to a person). Internal modifiers might include: physical or mental fatigue, knowledge, skill and expertise. External modifiers might include: the team around you, leadership of your team/department/organisation and equipment available. Both internal and external modifiers are affected by the culture of the organisation in which we work. Although there are signs of change, much of the past and current human factors/patient safety work has combined exhortations from government and upper echelons of the health service to "Be safer!" with grassroots work to find out what can and needs to be done. The latter exemplified, in the UK, by the clinical human factors group (CHFG) led by Martin Bromiley.
In May 2013 Andrew Hughes tweeted:
the problem with engagement events is that much of the thinking is vacant. culture is behaviour over time; let's just act! #nhsgosocialCulture is behaviour over time but the support, fostering and rewarding of that behaviour is a top-down activity. The first two sentences of the guidance explaining the UK's General Medical Council's (GMC) expectations of all registered doctors are:
— andrew hughes (@meantality)
Patients need good doctors. Good doctors make the care of their patients their first concern.Providing the environment to make care of patients our first concern is, in many respects, the responsibility of the organisation in which we work. Unfortunately the organisation inevitably has to balance conflicting demands such as financial and waiting time targets. Although these targets, such as length of wait in A&E, may contribute to patient care they are also likely to reduce patient safety. As an example, a patient on the operating list is going to breach their target for "weeks before surgery" and the list is running late. The safest thing for this patient may be that they are cancelled and rescheduled. The target however puts pressure on the theatre staff, who may be fatigued at the end of a long day, to carry on with the surgery for this patient.
What needs to change? There are a number of measures that may be undertaken to promote patient safety. "Human factors" workshops for all (senior) medical managers and healthcare personnel, face-to-face dialogue between management and the people at the sharp end and, lastly, unfailing perseverance by those who have embraced the patient safety culture to continue to "be the change you wish to see".
Post scriptum: You may be wondering why I didn't put in a picture of our theatre simulation suite and argue that this was the safest operating theatre in the world. In a future post I will discuss the simulation suite and the issue of safety for patients and for participants. In a nutshell, in the wrong hands the simulation suite may become an unsafe environment for both of these groups.