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Simple lessons for the NHS from a whistleblower Simple lessons for the NHS from a whistleblower
(7 months later)
I was the anaesthetist at the Bristol Royal infirmary who blew the whistle on the avoidable deaths of an estimated 170 children following cardiac surgery in Bristol. At the end of my evidence to the inquiry set up into the deaths, at which an NHS trust chief executive and two cardiac surgeons were found guilty of serious professional misconduct, I was asked what lessons could be learned. I said: "No institution, particularly in healthcare, can ever afford to lose sight of its patients."I was the anaesthetist at the Bristol Royal infirmary who blew the whistle on the avoidable deaths of an estimated 170 children following cardiac surgery in Bristol. At the end of my evidence to the inquiry set up into the deaths, at which an NHS trust chief executive and two cardiac surgeons were found guilty of serious professional misconduct, I was asked what lessons could be learned. I said: "No institution, particularly in healthcare, can ever afford to lose sight of its patients."
That was in 1998. It appears that, once again, the NHS has forgotten this simple lesson. So instead of denial, gagging and handwringing following the Francis report into the Mid Staffs scandal, how should NHS managers and clinicians respond to the complaints about quality of care? The answers to this question are simple, robust and effective. I have triedapplied them in the hospitals in which I now work, in Melbourne, Australia, and they have proved effective. I think they should apply from the centre of the NHS (Sir David Nicholson) to the most peripheral carer. The cost of doing nothing effective is £2bn each year – the cost to the NHS caused by healthcare errors. That was in 1998. It appears that, once again, the NHS has forgotten this simple lesson. So instead of denial, gagging and handwringing following the Francis report into the Mid Staffs scandal, how should NHS managers and clinicians respond to the complaints about quality of care? The answers to this question are simple, robust and effective. I have triedapplied them in the hospitals in which I now work, in Melbourne, Australia, and they have proved effective. I think they should apply from the centre of the NHS (Sir David Nicholson) to the most peripheral carer. The cost of doing nothing effective is £2bn each year – the cost to the NHS caused by healthcare errors. 
I propose four relatively simple, inexpensive measures.I propose four relatively simple, inexpensive measures.
1 An organisational commitment to quality and safety. Monthly "safety walk-arounds" should be conducted at the most troubled organisations. The presence of Nicholson would allow him to see at first hand the patients he is there to protect and the conditions in which they are being cared for. A series of repeated questions should be asked of care providers. Examples include: what is the next clinical error likely to be in your workplace? What barriers to providing good care do you experience most commonly? What can I do to help prevent the next breach of safety or quality in your work area? What would you do differently if you were caring for a close relative?1 An organisational commitment to quality and safety. Monthly "safety walk-arounds" should be conducted at the most troubled organisations. The presence of Nicholson would allow him to see at first hand the patients he is there to protect and the conditions in which they are being cared for. A series of repeated questions should be asked of care providers. Examples include: what is the next clinical error likely to be in your workplace? What barriers to providing good care do you experience most commonly? What can I do to help prevent the next breach of safety or quality in your work area? What would you do differently if you were caring for a close relative?
Seeing the head of the NHS asking intelligently about safety and quality will be a seminal experience for local executives and carers alike. The safety walk-around should be followed up by the same executives until the answers indicate that the problems are being solved. After three months, the organisation will be safer. Seeing the head of the NHS asking intelligently about safety and quality will be a seminal experience for local executives and carers alike. The safety walk-around should be followed up by the same executives until the answers indicate that the problems are being solved. After three months, the organisation will be safer. 
2 A sincere response to all incident reports. Most NHS organisations have relatively sophisticated incident reporting systems, which should give warning of systemic problems in delivering safe, high-quality care. These reports must be acknowledged. This validates the person who has reported the incident and ensures that potential "near misses" and actual incidents will continue to be reported.2 A sincere response to all incident reports. Most NHS organisations have relatively sophisticated incident reporting systems, which should give warning of systemic problems in delivering safe, high-quality care. These reports must be acknowledged. This validates the person who has reported the incident and ensures that potential "near misses" and actual incidents will continue to be reported.
3 Permanent "forcing functions" to reduce error The secondary response to incident reports must be to identify the causes of the adverse event and then attempt to put in place pre-conditions or "forcing functions" that will effectively prevent recurrence. For example, in eight hospitals across the world when a simple surgical checklist "designed to improve team communication and consistency of care" was enforced in the operating theatre prior to every operation, mortality fell from 1.5% to 0.8%, while complications, including wound infections, and unplanned reoperation, fell from 11% to 7%.3 Permanent "forcing functions" to reduce error The secondary response to incident reports must be to identify the causes of the adverse event and then attempt to put in place pre-conditions or "forcing functions" that will effectively prevent recurrence. For example, in eight hospitals across the world when a simple surgical checklist "designed to improve team communication and consistency of care" was enforced in the operating theatre prior to every operation, mortality fell from 1.5% to 0.8%, while complications, including wound infections, and unplanned reoperation, fell from 11% to 7%.
4 Encouragement is better than criticism When a busy hospital in Geelong, near Melbourne, encouraged nurses to acknowledge "drug-error-free shifts" with positive visual clues including smiley faces on a wallchart, the number of drug errors fell dramatically over the two months it was tried. Although not unequivocal proof of a beneficial effect of reward for error-free shifts, the example is indicative of what could be. I recruited the chief executive to endorse the changes and comment on the outcomes at the safety walk-arounds.4 Encouragement is better than criticism When a busy hospital in Geelong, near Melbourne, encouraged nurses to acknowledge "drug-error-free shifts" with positive visual clues including smiley faces on a wallchart, the number of drug errors fell dramatically over the two months it was tried. Although not unequivocal proof of a beneficial effect of reward for error-free shifts, the example is indicative of what could be. I recruited the chief executive to endorse the changes and comment on the outcomes at the safety walk-arounds.
I have no doubt that implementing any of these responses would improve patient care and staff morale in the NHS at a time when both are critically needed. It would also demonstrate that the NHS is prepared to care properly and will never again lose sight of its patients.I have no doubt that implementing any of these responses would improve patient care and staff morale in the NHS at a time when both are critically needed. It would also demonstrate that the NHS is prepared to care properly and will never again lose sight of its patients.
• Stephen Bolsin was anaesthetist at Bristol Royal infirmary (1988-1996). He is an adjunct professor and specialist anaesthetist at Geelong hospital near Melbourne, Australia• Stephen Bolsin was anaesthetist at Bristol Royal infirmary (1988-1996). He is an adjunct professor and specialist anaesthetist at Geelong hospital near Melbourne, Australia
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