In healthcare, too often we have seen that professionals are reluctant to speak up and report safety incidents in fear of the potential repercussions. This ‘blame culture’ is not new, and it’s impact can be wide-reaching, reducing the incentives around honest and open incident reporting, and impeding learning and improvement. A blame culture ignores system failures, attributing any error or fault to the individual, which either slows or completely inhibits the potential for learning.
For healthcare, moving from a blame culture to one of rapid learning is critical to facilitate continuous improvement and innovation. A robust incident-reporting system, which seeks to identify the root causes of incidents at a system level in order to prevent mistakes being repeated, is key to enable this transition (Radhakrishna, 2015). Reviews into the causes of the Mid-Staffordshire scandal have highlighted the need for this paradigm shift (Berwick, 2013; Keogh, 2013), and since then great strides have been made within the NHS.
Echoing these improvements, it was recently reported that the NHS Nightingale Hospital London recorded 144 safety incidents in 29 days (The Independent, 2020), demonstrating the successful implementation of a culture which facilitated rapid learning and improvements in patient safety. Speaking in a Royal Society of Medicine webinar, Dr Andrew Wragg described how this culture of learning was embedded in the organisation early on.
‘We also recognised from day one that we just had to be a learning hospital… If there was a safety concern raised on the Monday, often by the Tuesday we would have the learning required around the issue fed into the training of new staff coming on board.’
The NHS Nightingale Hospital, which opened on 3 April to provide surge capacity for the NHS as part of its response to the COVID-19 pandemic, utilised a selection of digital tools to capture real-time data to optimise patient safety. The ImproveWell solution, in particular, was used to gather insights from staff shift surveys and suggestions for improvement (read more about our work with the Nightingale Hospital here). Valuable insights can be drawn from the experience of the Nightingale Hospital as the NHS continues to embed a culture of rapid learning across the country. Undoubtedly, digital technologies will play an increasingly crucial role in this process.
- Berwick, D. 2013. A promise to learn – a commitment to act: Improving the Safety of Patients in England. Available here [accessed 15/07/2020].
- Keogh, B. Review into the Quality of Care & Treatment provided by
- 14 Hospital Trusts in England. Available here [accessed 15/07/2020].
- Radhakrishna, S. 2015. Culture of blame in the National Health Service; consequences and solutions. Available here [accessed 15/07/2020].
- The Independent, 2020. Coronavirus: London’s Nightingale hospital recorded 144 safety incidents in 29 days. Available here [accessed 15/07/2020].