Why Don’t Hospitals Learn from Mistakes? ‘History repeats itself. It has to. No one listens’ (1).
It seems common sense that we learn from our mistakes. It would be good to think that hospitals would do the same particularly given that their mistakes are a matter of life and death. However some recent research suggests that healthcare organisations only rarely do so, in contrast with other industries such as air travel, oil exploration and nuclear power (2).
Dr Paul Grant, Diabetologist at Kings College Hospital, suggests 2 organisational reasons. First, there is a culture in which people are inhibited from voicing concerns or questioning whether other, perhaps more senior colleagues, have got things wrong. The second is that hospital practice is better at dealing with quick fixes than understanding root causes.
The challenge then is to find ways not just of changing systems but of changing a culture – ways of thinking, patterns of behaviour and underlying values.
Interestingly there is evidence that successful damages claims where negligent acts have caused injury have forced hospitals to improve care in certain areas. One notable example is managing labour. Although claims for serious brain injuries to babies at birth are few and far better, successful claims give rise to payments often amounting to several million. These claims have forced hospitals to review and improve their care. It is ironic therefore that the government’s plans to restrict access to justice and make it harder for the victims of medical negligence to obtain redress for wrongs in the interests of saving money will probably increase NHS costs and reduce patient care. Claims are at least one way of encouraging hospitals to learn from their mistakes.
(1) Steve Turner
(2) Grant, P: ‘Doctors Attitudes to a culture of safety: lesions for organizational change’. Clinical Risk Vol 17 No 5 September 2011, 165-170
Paul Sankey is a Clinical & Medical Negligence Solicitor at Slater and Gordon Lawyers. For a free initial consultation call freephone 0808 175 8000 or contact us online and we will call you.