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Errors, Near Misses and Good Outcomes

Updated: Dec 5, 2019

The third in a series of workplace culture blogs written by Stacey Blease on behalf of VetLed


Learning From Excellence


If it seemingly ‘ain’t broke’, should we bother trying to make it better?


The previous articles looked at attributes of continuous learning and making improvements when things go wrong or when an error is narrowly avoided. Errors happen less frequently than aspects of practice which are performed correctly. Should we wait for a mistake or near miss before trying to improve how we work? If it ain’t broke, don’t fix it, right? I disagree. If you are like me and you ask someone why they do something, and the response is, “because that’s the way we’ve always done it” alarm bells will start ringing. This article looks at the benefit of learning from the gap between what best practice suggests and what we actually do, and the advantages of learning from excellence.

Suzette Woodward who is the former Director of the ‘Sign up to Safety’ campaign suggested that in order to obtain a complete picture of patient safety we should be looking at both ends of the spectrum of successes and failures. ‘Safety I’ is more of a reactive approach of how processes can change as a result of a specific error compared to ‘Safety II’ which is proactively assessing current methods or techniques and determining the successful aspects of them (NHS Patient Safety Strategy video). I really like the Sign up to Safety tagline which is “listen, learn, act”. I am completely onboard with this!



Adopting assumptions


You might be thinking what’s the point of looking at processes which have not resulted in some kind of failure. In her video Suzette discusses the difference between work as intended versus work which is actually done. Assumptions can be dangerous. There may well be standard operating procedures (SOPs) outlining best practice but what is actually happening on a daily basis? If there is a gap between how we would like to do things in order to improve patient safety, health and welfare, and what is actually being done, the gap could lead to errors and near misses. In order to investigate the gap, it would be really useful to have a just culture, otherwise when asking or observing your colleagues to ascertain how certain tasks are being carried out on a daily basis you might get a model answer or performance if they feel that they are being scrutinised. Framing the exercise in such a way that we would like to close and hopefully eliminate the gap, we need to understand why particular steps are missed in the SOP so that we can overcome the barriers together.



Appreciating excellence


Focusing on errors or gaps in what we say we are going to do and what is actually done, both of these come from places of inadequacy of some kind. Can we learn from what we do really well? Yes! This is another aspect of safety II. Understanding what factors are needed for success helps to provide a framework which can be applied to other situations.

I came across a ‘Learning from Excellence’ pilot study performed by an obstetrician and researcher in a hospital in Dublin. For one month, forms were distributed requesting examples of individuals and team excellence from all of the hospital departments. Using the feedback from the 18 teams and 27 individuals who were described as demonstrating excellence, four themes were identified: “excellence in daily work”, “identifying problems, proactively solving them”, “emergency care” and “educational initiatives” (Higgins, 2017). In the article Dr Higgins expresses the importance of the fourth theme of “educational initiatives” underpinning the other three themes and is essential for clinical care. This kind of initiative which celebrates successes can boost morale and appreciation, aid collaborative learning and further enhance patient safety.



The excellence, the errors and the gap


There are different sources of information to improve the safety of our patients. We can champion examples of excellence, learn from mistakes and examine the gap between the two. With this three-pronged approach to obtain feedback and subsequently apply it in practice will help to further improve patient safety. The presence of a just culture cannot be underestimated to support the reporting of accurate information when near misses and mistakes occur. In addition, adopting a growth mindset will assist in responding objectively to learn from the incident and if you are the person who shares the feedback with the team, not to create a threatening situation resting on the shoulders of specific individuals. Instead it is important to frame it as a collaborative challenge for all team members and the practice to support the commitment to continuously assess how to improve patient safety.


References:

NHS Patient Safety Strategy: Suzette Woodward on Safety II https://www.youtube.com/watch?v=Oq-c5fXFhuE

Higgins, M. (2017) Learning from Excellence as the first step in Appreciative Inquiry: Experience from a tertiary level academic maternity unit. MedEdPublish https://doi.org/10.15694/mep.2017.000005


After graduating from the University of Liverpool Vet School with an intercalated Master’s degree from the Royal (Dick) School of Veterinary Studies, Stacey worked in general practice. She completed her PhD at Harper Adams University on dairy herd health planning. Stacey has worked for an online CPD provider, The Webinar Vet and the British Veterinary Nursing Association (BVNA) as the Head of Learning & Development. Currently, Stacey is a trustee for the Animal Welfare Foundation (AWF). Stacey's experience is diverse and her passions include research, education, organisational culture and innovation.

©2019 by VetLed. 

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