So here is the thing; I often find myself describing what has gone wrong with healthcare; that is not to say that the vast, vast majority of care that is provided in the UK, whether in health or social, is fantastic – amazing, delivered by committed, caring, compassionate people, who get it right, almost always.
Yes, they are our there, in fact, they are everywhere, you see, we ‘people’ are essentially good – we get the job done, on time, and, on budget, as the adverts say. The circumstances when things go wrong – in other words, failures, errors or mistakes, are few in number and more often than not, because of factors that boil-down to us being people; aka, human – human all to human, as Nietzsche says; we call this ‘Human Factors’ in medicine and the risk-world – the things that happen because we are humans, not robots or computers.
One of the fundamental aspects of Human Factor learning is acknowledging that we, as humans, have limited ability, foresight and concentration. We struggle to remain focused on one area for long periods of time, we aren’t one hundred per cent consistent in our movements or actions, we respond to outside influences that exist in a complex world – our actions and reactions are often beyond our control, determined by an infinite number of possibilities that are being human.
So, when I describe things that have gone wrong, where care is not delivered in a fashion that we would expect, medicines are late, wrong investigations offered, appointments missed, or the wrong operation performed – this is not, in general, or perhaps, universally, with the exception of the odd offender, intentional.
Indeed, for those people who aim to sow chaos, harm and disruption, there are far better ways to earn a living; I think Hedge-Fund managers and stockbrokers discovered this a long time ago.
That, therefore, is my explanation for raising the issues that I encounter, when things go wrong. Like the patient I met recently who received not only the inappropriate medicine – he has a form of dementia that can result in a catastrophic reaction if given certain drugs; yes, he was given the wrong medicine; not only that, he was given ten-times the recommended dose. The patient survived. He is unable to tell me what is was like to experience this – perhaps a sudden, terrifying inability to move, to breathe, to see.
And, that I guess is where I return to Human Factors – it is no good my complaining about the doctor who prescribed the medicine, the pharmacist who dispensed it, or the nurse who administered it, what I really need to be doing, is looking at myself and enquiring, how I could have prevented this from happening.
There is a bit of cynicism around training and education at the moment. I am not sure why, perhaps, because of the way it is sometimes rolled-out at the panacea to all ills, as the solution when bad things have happened; last week, I heard someone allude to the tyranny of education.
I don’t see any other way out of this however; sure, we can design systems that prevent things from happening, or at the very least, make them very difficult – like the learning that occurred after intrathecal chemotherapy was administered, fatally, by error, to children in the UK and around the world; the design of the equipment has now changed to prevent this from happening again.
The problem is, when working in what Professor Dave Snowden of Bangor University calls ‘Complex Systems’ – environments when what is happening is unpredictable and the pressures, influences and demands internally and externally on that system are outside of any control mechanisms, there will always be situations that we can’t predict, eventualities that have conspired because interactions have taken place in unexpected and unprecedented ways.
And this, I guess, is what it is to be human, or perhaps, what makes life worth living, and in essence, why things go wrong, despite training, education and development, pathways and guidelines, best and good practice, mentors and monitors.
We are human, all too human.
The next time I describe things going wrong, please think of this, realise that I know there aren’t bad people out there – you don’t become a doctor or a nurse, you don’t work in a hospital if you are bad, there are however people out there, humans who are vulnerable, just like me, to things happening.