On Friday I attended the Yorkshire and Humber Patient Safety Collaborative ‘One Year On’ conference. A number of speakers from the region discussed the work they are doing to make predominantly hospitals, but all care in the wider sense, safer, less likely to result in inadvertent harm.
Primum non nocere – first, do no harm, is at the heart of all medical philosophy; consequently, over time, patient safety has become a bigger and bigger issue – it is no coincidence that those NHS organisations that place ‘safety and quality of care’ as their number-one priority (beyond finance, reputation and even customer or staff satisfaction) tend to be also the most successful.
One of the speakers, Debbie Clark, who is senior lecturer in Human Factors at Sheffield Hallam University, described aspects of human behaviour that unless controlled, managed or at the very least acknowledged, can become major risks to patient care – such essentials as being kind and respectful, listening, paying attention, allowing others to speak – i.e. basic humanity, which can often be lost in the systematization of ‘care’ – and here, we are talking, both health and social care, with the result of errors taking place, such as planes flying into mountain sides, as described so well by Malcolm Gladwell.
And behind these errors, which are often described as ‘system failings’ – where the Swiss Cheese model of causation described by James Reason comes into play, are the actions of individuals – their either direct or indirect involvement in ‘harms’ of which they are frequently unaware.
Forgetting to wash your hands, misinterpreting or misunderstanding the meaning or intention of a patient or colleague, misreading a prescription, mistaking an allergy status, etc.
In a recent This American Life episode, ‘The Leap,’ the presenters describe a Pew Research Centre study, which looked at the thoughts Americans have about the future and the future of technology.
The final survey question was open, asking, what if any, scientific technology would the participants most wish to have available to them. Ten per cent of those asked said, time travel.
This would equate, if the results were generalisable, to 30 million Americans having as their number-one desire from future technology, an ability to go back in time or travel into the future – most preferring the past. (More than those wanting to cure cancer, hover-board or teleport)
Within this desire, was however, the well-known ‘ripple effect’ – described in ‘Back to the Future’ as Doc and Marty’s ‘space-time paradox’
It got me thinking about all the ripples in my life, when I leave the house a few seconds early in the morning and the ripples that I must send-out over the universe, when I make a decision that impacts on the life of an individual and their family in ways that I cannot imagine.
We can never understand this effect – it resides in the realm of the metaphysical; we can however only do our best, acting humanely and sensitively that is, as my parents would have described, in Yiddish, ‘being a Mensch’