Encore Release: The Real Reason Training Alone Cannot Fix Patient Safety

Speaker A: Hello, and welcome back to Turn on the Lights, brought to you by IHI, uh, the Institute for Healthcare Improvement. I am Philip McAdoo. Today we're revisiting another one of our most popular episodes, the Real Reason Training Alone Cannot Fix Patient Safety, with Professor Charles Vincent. And the title says a lot. Training matters, we know knowledge matters. But patient safety cannot depend only on asking people to try harder. This conversation reminds us that safety is shaped by the systems people work in, the pressures they carry and. And the conditions that either support or undermine care. Safer care requires more than individual effort. It requires systems designed for safety. Here's Professor Charles Vincent.

Speaker B: One of the important continuing frontiers in improving healthcare is to make it safer. It's still true, despite decades of research, that we know that healthcare is a hazardous enterprise. People are trying hard to keep patients safe, but things do go wrong. There is, luckily, a collection of researchers and advocates around the world now who have been working on patient safety for decades and have developed a tremendous amount of scientific understanding about how things go wrong in medicine and why they go wrong. Our, uh, guest today is one of the leading scholars in this field. It's Professor Charles Vincent. Charles is a clinical psychologist who moved his research in the late 1990s into the field of safety and what makes complex things safe and not. He's been a leading thinker in the safety movement in healthcare and one of the deep students of the psychology of safety. What is the psychological background to human error and how to protect patients through changes in the environment in which the clinicians are working. He's also a close colleague and friend, and it's a delight to welcome you, Charles Vincent, to turn on the lights. I'm thrilled to have you. We've been friends and colleagues for many years and I'm really happy to introduce you to our audience.

Speaker C: It's a great pleasure.

Speaker B: Dawn Charles, Maybe m say a few words about yourself first. Uh, we can give the formal stuff, but tell us about, about your background and what your activities have been.

Speaker C: In our nano, I began my career. First, I was a nursing assistant for a year, which was very instructive in a psychiatric hospital and acquired a lot of responsibility at a very young age, which was when I was just a feckless youth. Then I, uh, trained as a clinical psychologist and I worked in the rnhs, the British nhs, for several years. And then I became a researcher and my first job was on a project called Avoidable Mishaps in Medicine. It's a very polite title for looking at disasters in the 1980s. And since then, in one way or another, I've been looking at risk, medical error, how to make healthcare safer, uh, how to improve healthcare. And following a parallel track to you in as a researcher though.

Speaker B: Well, as you're too modest to say it, but I'll tell our audience you're one of the really premier researchers and developers of modern approaches to improvement in very complex systems, including healthcare. Whatever got you interested in things that went wrong or that's what drew you into that as a topic to devote yourself to?

Speaker C: I was trying to finish a Ph.D. and uh, it was part time. I had no funding. I had I think four or five, maybe six different activities, several jobs part time and the whole thing was a nightmare. And I needed a job. And a job came up in the department in University College London in psychology, where I was doing my PhD. The job was on avoidable mishaps in medicine. So it was the study of accidents came about by accident.

Speaker B: Uh, tell us, what's an example of an unavoidable mishap? What is something you encountered that falls into that category?

Speaker C: The uh, avoidable or unavoidable things?

Speaker B: Either you pick.

Speaker C: Okay, so the avoidable in the original project, which was a very long time ago now, this was funded by a medical legal company, insurance company for doctors. And they were concerned with, particularly with mis. Uh, fractures, particularly in the emergency department, various maternity cases as well, brain damaged children. These were the things that people were concerned with at the time, mainly I think because they were identified, because they led to litigation at that time. I don't think anybody had any idea of the scale of harm. This was before Lucian Leap and everybody's, before the Harvard Medical Practice study came out. So it was. These are the sort of incidents people were worried about. And we did early studies on looking at the medico. Legal. The legal records and the medical records of babies who'd been brain damaged and where cases where obstetricians had judged there was some sort of problem. And very early on we found that it wasn't random errors. There were themes, lack of supervision, poor monitoring, if you like, systems themes coming through these tragic cases. So this was an early sort of. Probably around the time I started to hear about Jim Reason and understand accidents in a different way. But these sort of thematic aspects of the whole thing were quite new I think at that time. Certainly new to me.

Speaker B: Jim Reason was the great scholar of human error. He passed away very recently. And uh, what was it about Reason's work and his point of view that uh, caught your interest?

Speaker C: Well, we too were interested in Errors because this is what litigation focused on. This is what the people funding us were interested in. How do you stop these errors? And I suppose psychologists have been interested in, have been studying errors for decades, often with a view to understanding ordinary functioning. But I suppose that was primarily how we were thinking about it. And I went to my boss, Professor Bob Ordery, who was responsible for the project and wonderful man, he was a friend of Jim Reason's. And I went to a meeting in the Royal Society in London where Jim was speaking. And I remember the impact was astonishing on me and many other people when I heard him just give a completely different account of how things went wrong and talk about latent conditions, the factors that might lead to people making mistakes and that it was not much help really. People are always going to make mistakes. Just that's life. But what you could look at was why were they tired, hungry, Were the procedures terrible? How could you improve the teamwork? How could you improve a system overall to make it easier for people to work in? That was basically the idea and the idea in many industries outside healthcare. But to hear Jim talk about this was a revelation to me.

Speaker B: What was the pre existing theory you had in your head about errors? Let's talk about reasons. Approach. But what before reason? Let's say what, uh, how were you thinking about errors that, that you changed once you heard about this new way to think about it?

Speaker C: I don't think I thought that they were evidence of bad character or anything like that. As I think people, as is widespread in healthcare, if you made a mad mistake you must be a bad doctor or bad nurse or whatever. There's an awful lot of that thinking still around now. It's not so much thinking, it's a sort of gut feeling. I don't think I ever thought that, but I suppose I would have thought about it that if we were going to uh, improve things it'd be a matter of training or it'd be a matter of understanding cognition or why particular things happen. And I think that's probably also the kind of thing we were looking at early on were rather particular errors. We became quite unpopular. My friend Peter Driscoll and I was an emergency doctor for discovering that in the emergency department in central London, junior doctors missed a third of serious fractures. I broken hip and things like that.

Speaker B: One out of three.

Speaker C: My goodness, one out of three. Mostly they were picked up later by somebody but maybe 24 hours, 48 hours later. So it looked like a problem of doctors not knowing what they were doing. Though Peter showed me these X rays and I couldn't see the breath fractures. So I wasn't feeling too superior about it. I think later when we looked at maternity, when you look at incidents that huh, evolve over several hours, maybe a day or two sometimes. Oh, it's not really about errors. There's quite a story here. And then we've started to understand, need to understand the stories and all the factors that play in and the whole idea of an error begins to break down. When you begin to look at the stories, tell us the story.

Speaker B: What do you mean by a story when you're looking at an error of missed fracture or a maternity?

Speaker C: M. Maternity. Well, I'm no expert, uh, I've just. I'll stick with maternity. Not because I'm any kind of expert on it at all. And it's a long time since we did these studies. But I suppose when you look at a tragic outcome and an obstetrician might write a report saying this could all have been avoided if they just recognized the emergency and done the caesarean, then this baby would be okay, whatever it might be. But then when you read the reports and you read, perhaps read the report of a midwife looking, saying, actually the problem started three months ago. This woman had high blood pressure, whatever it was, and various problems. This was not picked up in the antenatal visit. And then the woman herself missed this appointment. And then there was a delay getting to hospital. When she did get to hospital, it'd be very slow acting on it. And then there was this period when they didn't really monitor her property for several hours. What was going on there? And then they didn't call the senior doctor fast enough. So why did that happen? All of these things start to play in to the eventual problem.

Speaker B: Yeah. How do you now really at the pinnacle of the research community on error, how do you now think about that series of which we call the mishaps or errors? What would you say is the mo. The modern, the informed way to think about that kind of story that you just told?

Speaker C: I suppose I still think about it much in the same way as Jim Reason does. I think not everyone does. I think about it as a. The questions I ask are different. I think I say what is it about this system that allows these things to happen? And that's perhaps a more productive question than saying, why did somebody do this wrong? It's not that I think you can't study people's individual mistakes. I think you can. But they're normally firstly just part of a much bigger picture and the contribution Especially in something as complex as medicine, when you've got teams of people looking after a patient in almost every environment, the contribution of any one person is usually relatively small to a tragic event. And also, I don't think, I think at ah, that point time we and everybody else were focused on the big events. And that's, I still think that's an understandable and correct. We should give more attention to those sort, uh, of events. But I suppose underneath that I see a background of systems working not quite as they're meant to and minor problems happening all the time in healthcare, lots of other systems too, but particularly in healthcare, where people I think are quite, perhaps compare with other industries, quite tolerant of uh, not following procedures, getting away with it, doing things in a bit of a rush, being tired, being hungry. All of the things that in ordinary life we would know very well would we'd be underperforming. And I see that sort of continuous background as occasionally giving rise to disasters. And I don't think I saw it that way early on. I thought I saw mostly of the big problem. Now I see the system generally as being very vulnerable to problems. If that's not too abstract.

Speaker B: No, I think it's. But it is a different way to think. Do you believe, maybe you haven't formed an opinion on this, but do you believe that when things go wrong in medicine today, a, uh, diagnosis, mistaken diagnosis, a missed fracture, uh, uh, too much delay that harms a patient. Do we have a culture which is attuned to this system view, or is it a culture more oriented toward finding someone to blame and maybe even punishing them or correcting them? Where are we in the development of our understanding of the psychology of error?

Speaker C: I suppose it varies from m. Place to place, from country to country, from culture to culture. It varies from person to person. I suppose in England I'd say that the idea that we should look much more at the system than the person most of the time is well publicized. It would be quite unexceptionable to say that now, and that wasn't true say 25 years ago. Nowadays it'd be ordinary. But it doesn't always happen in practice. And I think often the gut reaction is to find somebody to blame. It's very instinctive as a human thing. And I think often when people panic when organized, particularly when organizations get nervous and defensive, then they do some very nasty things, sometimes to their employees. It's very different, I think, to how it was perhaps years ago. But every clinician knows of colleagues who've been wrongly Castigated, if you might say, or I'm badly treated. But it's curious. I don't think that we shouldn't blame people. I think it's much more we blame people for the wrong things. I think healthcare is very odd in responding very badly and oppressively punitively, if you like, to people making mistakes and being far too tolerant of people behaving badly or disrespectfully or being excessively hierarchical and dominant, which is in itself dangerous. Very tolerant of poor behavior, as you might say, and intolerant of error. That's a rather. I'm caricaturing it. Yeah. Rather curious situation.

Speaker B: Are you willing to say what you mean by a bad behavior? An example of that. And then what is its connection to errors and safety?

Speaker C: Let's take a couple of examples. We know said, if you think about the World Health Organization surgical safety checklist, which is now pretty well embedded, I would guess, in the UK and in many countries. And I would also think probably that for most young surgeons and anesthetists growing up and coming through the system now, it's a very ordinary thing to do. And yet I would also imagine that there's quite a number of senior clinicians who can't be bothered to do it or do it in a way that shows their disdain for running checks that might protect their patients.

Speaker B: Just for those who don't know, what is the surgical safety check? How does it work?

Speaker C: It's just a series of routine steps, checks that are done before an operation. Rather analogous, if you like, to the checks that pilots make before they take off. So you check. You would probably know this better than me. Donna's alarm. Um, but you check the identity of the patient. You check they've had the antibiotics at the right time, but you also do some other things, like introduce people in the operating theater to each other, if need be, we should say. Which has the effect of perhaps making things a little bit easier socially. And the particular reason for doing that is that you hope if there's a problem, people will speak up and feel able to speak up. So to be disdainful about those sort of practices sets a very bad tone in the theater. It keeps everybody not willing to speak up and clamps everything down. So there's that kind of behavior. Then there's just sort of behavior like being very rude and dismissive to people and domineering and this sort of ordinary things that you see. But it's particularly dangerous in any safety critical environment because safety relies partly on doing things properly and following procedures and all that sort of thing. But you, that's never enough. And you always rely on a very open communication and people being willing to talk to each other and say, I'm um, not a bit worried about that, or are you sure that's right? And all this sort of thing. And you can't have that open free communication if you've got people being unpleasant, disrespectful, nasty to reach to junior people, for instance. It's not only unpleasant, um, it's dangerous. And as a patient, that's how I see it.

Speaker B: So what is to be done about it? What helps make things safer on both counts, both understanding the system's view of error and also this issue you're raising about behaviors that, that need to be dealt with.

Speaker C: Well, on the systems view, I think it's funny, we haven't, we've made quite a lot of process improvements in the sort of quality improvement, but haven't paid enough attention to say, the usability of medical equipment interfaces, anesthetic monitors, for instance, or the conditions in which people work. You know, poor lighting, noise, distraction, all this sort of thing. These would be system changes which would help things a lot. On the bad behavior side, I'm, um, no authority on this. I would just like to see less tolerance of it and I'd like to see it seen by managers, by senior leaders as a safety issue, as I think people would in. People don't like comparisons of aviation. They think it's too crude. But I think it would certainly be seen that way in commercial aviation. Behaving, whatever your personality, just behaving in a sort of respectful way is demanded. It's not. I think healthcare still has a history of mavericks and people feeling it's okay to behave how they like. Not so much as perhaps it was.

Speaker B: You think it's changing?

Speaker C: I don't know. You would know better than me probably.

Speaker B: Yeah, yeah.

Speaker C: But you should chip in your own examples, Don, for this because you'll remember

Speaker B: many instances, oh, I think you're doing just fine. How to intervene, I would say when behaviors are not okay in terms of deteriorating the climate for safety, you've got to have senior. I think it's correctable maybe not only but best by senior leaders who are explicit about the culture that's going to support great patient care. And I think sometimes little reticent to speak up. Indeed, remembering my own training, there's almost a sort of bizarre romanticism about the rude doctor or surgeon who's admired by everyone, the best there is and gets, gets to behave any way they want. I don't have much time for that, but I think it's still a pretty prevalent.

Speaker C: Yes. Uh, it's one of these bizarre myths. Artists have to be reckless and unpleasant and treat their husbands or wives badly. It's all part of their greatness, rather than thinking, well, they're great, but they're also awful as people.

Speaker B: So your work has been massive and you've done an awful lot that's been very important, I think. Would I be wrong to say that some of it centers on this, what you've been talking about, which. Which in our world we would call psychological precursors or psychological safety. It's the psychology, ambient environment, uh, that relates to the probability that someone will either experience an error or not speak up when there is one. Can you dive into that a little more your own research and what it is you discovered?

Speaker C: I hadn't really worked directly on what would be called psychological safety or safety culture. These are terms that are often used and bandied around. I think they have a meaning, but they're quite general. But I think I have. For instance, I used to work in surgery for 10 years, but I worked in a department of surgery. I'll use some examples from there because when you break it down, I think the color of the word culture and the sort of ambience is. It's quite hard to pin down. But once you start doing studies on surgical teams. We used to do studies where we would have observers in the operating theater. And the observers often would be a psychologist and also often a young surgeon, very experienced. Actually, they might have been in the operating room for 10 years. But when they stood at the back and watched, they would often be surprised by what they saw, even though knew the environment intimately. So they might be just surprised. Perhaps it might be to do with looking at the way the equipment was laid out, that people were moving across wires or the monitor was in the way, or that people kept walking in front of the monitor, in front of the anesthetist, between. So they couldn't see the monitor. There's all that sort of ergonomic stuff. They would also begin to notice that communications were not followed up, or when people weren't listening, or when they were intending to listen but distracted, or when people were a bit snappy and not really listening when somebody was saying, look, we've already got a problem here. I need you to pause. I'm worried about the blood pressure or something like that. So this is more than just cultural and psychological ambience. But they would begin to see A lot of minor problems which were making life difficult for the people and therefore degrading team performance. And that's what I mean by the sort of background detriment, where a team is just. They're not performing badly, but they're on the edge and drifting, if you like.

Speaker B: So this is interesting. Um, these were people who had worked in that environment for years, but you had. Did you see. You have to take them out of it so that they can see this, so they can observe these.

Speaker C: We were using. We were developing measures, measures of team performance, measures of leadership, communication, coordination and so on has been done in other areas. And the people these surgeons were often doing, or anaesthetists were often doing PhDs or nurses actually, as well. So part of it was to actually observe surgical teams actually to watch and to see not what you assume is happening, but is actually happening. And they were surprised. Not. It's not as if there were things happening that they'd never seen or never encountered, but because. And it's nothing to do with surgeons or anybody, but if one is busy, if you're busy and you're operating on someone, you're managing anesthesia, you can have some sort of situational awareness, but you haven't got the leisure and the mental space to actually watch what's going on. Otherwise you'd be neglecting your patient. So you have to stand at the back and watch in order to see the whole picture and to see why teams. To observe a team working well or working badly or not so well or fragmenting a bit. And, uh, it struck me very much. And I can say it's not a point about surgeons. It's a point about how any of us can work in an environment for decades. I'm sure if somebody came to watch me working in the university, or certainly watch universities working a lot of things, you think this is absolutely ridiculous. Why are they doing it like this? It's that sort of mindset. You need to think, uh, about safety.

Speaker B: Many of the people listening to this conversation are not clinicians. They can't change their own practice. They're. They mostly encounter healthcare as patients. If you're in that role and you're about to have surgery or encounter. What advice would you give to people now who want their care to be safer, but they're on the other side of the desk. Can patient. Can people do things that make things safer by building on the work of Jim Reason and you and other scholars?

Speaker C: Yes. It's a big question. I think the first thing I want to say to Somebody is that the awareness of all these things is hugely greater than it was when I first started, and the training where it is, among the professionals. Among professionals. I don't want to give a message of panic. Surgical outcomes, for instance, have improved dramatically in the last 10, 20 years for many reasons. Safety interventions, technology and all sorts. So it's not a question of that. And healthcare's placed a great deal more emphasis on safety than in the past. You can see the outcomes for HIT operations or whatever it is. And I think when you're in hospital as a patient and if you're feeling very sick, probably the best thing you can do is forget all about all this stuff and let people look after you and get better. I think it's probably more important to ask questions and be very clear before you enter a hospital when you're considering the decision to have an operation, to be sure. Because sometimes surgeons would agree, because as patients, we push them because we want the. A cure for whatever and to be cautious about having treatment, generally. Not cautious in the sort of anxious way, but just quiz people a bit, what's this? Is this really going to help? What's the best outcome? What's the worst outcome? What could go wrong, but what's realistically good? And certainly, I, uh, think it's a hard thing to do, as I know from being an osp, being a relative, to ask questions if things are missed. And I think often it's perhaps not so much in the operating theatre, but on the ward. Nurses are very busy. The drugs have. I had my drugs, actually has been given his drugs today. Check, ask questions. But it's difficult. You have to prepare to be a nuisance, but that's probably necessary, I suppose. The other thing I'd say is for patients, of course, is that we think a lot about hospitals, but I'm also working now with a team on care in the home. So Mediclara, which used to be just for doctors and nurses and other professionals, patients and families can now make errors because the more complex care goes into the home, the more patients and families are taking on, um, big responsibilities at home. And they too are facing the challenges of keeping their family members safe. And part of that is managing quite complicated medical equipment. So that's another wider story.

Speaker B: Part of this progress that you're seeking to make in understanding and mitigating risks may have to do with the preparation of health professionals, especially young professionals. Is this kind of stuff getting into the curriculum now of medical students and nursing students and young people being made aware of the Science and do they care? Are you getting positive response, negative response?

Speaker C: I don't know quite what's happening in medical schools and so on, but my impression is that very little of this sort of stuff is in medical schools and nursing schools and what there is rather bureaucratic. And it's only perhaps later when people do graduate degrees or get involved in say, simulation centers where people are really training with a lot of knowledge of this, that there are now quite a lot of clinicians who are very deeply engaged in all this stuff. But it probably comes later in their careers, I think.

Speaker B: Um, Charles, in the us, I don't know about the UK for sure, but one of the, uh, theories of making healthcare better, including safety, is all payment, that we're not paying properly, that we're not attaching the correct incentives in this case to patient safety. What would you say to that in terms of its concordance with what we now understand scientifically?

Speaker C: You would know a lot more about the payment incentives and the structures and so on. And it's certainly relevant. And I would say obviously we have a public funded system, but I would say certainly that for us I think it's not so much incentives, but I think we do. Managers and executives in the nhs, in the British NHS are uh, so focused on money for understandable reasons because that's what they get judged on, that's what they get sacked for failing to meet the budget. It's not that they don't care personally about safety, but professionally I don't think it gets much of a looking and I think there's almost zero discussion of what I would call the trade off between productivity and safety, that if you push more and more patients through a system it's going to get less safe. This is not just true in healthcare, it's true in railways or oil or aviation or whatever. Um, but I think in those other industries, my understanding is from colleagues who work in them, there's a much more explicit discussion of these problems and how to manage it. Whereas healthcare, we have no barriers really. It's just however many patients you can push through, push more and no real, the uh, clinicians may say, but it's not an explicit discussion of at what point it really gets dangerous. The other thing to say about the incentives is that, okay, you can have incentives and I'm sure we, I'm, um, no economist, I'm sure you could structure the incentives a bit better to make the system a bit safer, but on its own you've still got to know after that how to make the system Safer. And that's not so simple even if you have the incentive, which we don't.

Speaker B: Yeah, that's a form of frustration when you're banging the table with money or otherwise saying do better and we don't have.

Speaker C: Yeah.

Speaker B: The help and capacity and systems to support that. Charles, I can't thank you enough for joining me. You're, and for your work. You've been really a hero of mine in terms of the way you've contributed to understanding and uh, in this really important field. And I, uh, appreciate that we have a tradition as we close these interviews to ask the same question to all of our guests. Let me ask you. It's the optimism to pessimism question. Like you've been around a while now in this field. You've certainly contributed, but we still have problems of, uh, safety demoralization and misunderstanding in healthcare, both of our countries. Are you optimistic about where we're going to get to or are you feeling a little frustrated and that maybe there's not so much cause for optimism at this point in terms of progress or patient safety?

Speaker C: No, I'm optimistic in the sense that I think we have made a lot of progress. It's transformed since I first began. But what I think is now, which I perhaps didn't, perhaps I thought we might one day become safe. But I think now, I think that the whole business of safety is, uh, a never ending problem. And not just for healthcare, but everywhere because everything changes. As I've written with Rene Amalberti, uh, particularly safety in healthcare is very difficult because it is a moving target. As healthcare improves, as we get better, we acquire new safety problems for a variety of reasons. We have new technologies, we have new risks, like care in the home is great, but then it brings new risks. And also as healthcare improves. Sepsis was not a safety problem 15, 20 years ago. Now it is. But that's because people have got better at managing sepsis. So now it's a safety problem. So as our standards improve, we have different safety issues. So it's quite a complicated assessment. I remember you wanted a simple answer, and I've given you a complicated one.

Speaker B: It's a great answer. You reminded me of Jim Reason at a meeting we were both at with him when he, I remember he said that safety is a continually emerging property of a dynamic system, which is a little, uh, more complex way of saying what you just did, which is it's always changing. We're never done with safety. You have to keep at it because the world's changing.

Speaker C: Yeah. So at least well, we stay in business. Yeah.

Speaker B: Well, luckily for us, you are. And I hope you'll continue to write and do your research and look forward to seeing you again in soon. Charles Vincent, thanks for joining us on Turn on the Lights.

Speaker C: Thank you, Don. It's been a pleasure to be on the podcast. Thank you.

Speaker B: I hope you enjoyed not just the content of the conversation with Charles Vincent, but also the tone. I deeply admire him as a scholar, but also as a human being. His whole attitude seems to involve a sense of maturity and peacefulness that I really take heart from. He has understated in the interview the importance of his research. He's one of the people in the world who's contributed the most to understanding the psychological conditions that lead to safety in organizations and teams. He is a gentle advocate for rethinking how we are approaching safety. And the message I always take away is that blame doesn't help. Almost never. Charles is thorough about that. Sometimes people need to be criticized. But this culture of individual accountability, the use of blame and shame and finger pointing and punishments in the world of safety, it just doesn't help. And if you listen to him and what he and Jim Reason and other scholars have brought to us, it's asking us to take a deep breath when something goes wrong, to understand there's a whole system of interaction, a whole collection of events and preconditions underway that lead to the event that you're looking at. And very often the person who's at the sharp end of that, the patient and the individual doctor or nurse, for example, can be totally misunderstood if you don't realize the system of conditions that they're swimming in, which frankly, would mean that almost anyone would have made an error under those conditions. You can access Charles Vincent's work. I urge you to do it on, um, Google and you'll learn a lot about more mature way to think about things going wrong in medicine. And as they get better, we're going to have Charles Vincent to thank for a lot of that progress. Mhm.