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We had the opportunity to interview Alison Walton, Patient Safety Manager, NHS South East UK, who is the International Keynote Opening Address at the Adverse Events Conference 2012 in Sydney on the 20-21 September.
How crucial is open communication in reducing adverse events?
It’s perfectly possible to introduce change to practice, policy and equipment to bring about change with no more than bald instruction, but the more that staff understand the reason they are being asked to make a change to the way they work the more likely they are to adopt that change and encourage others to do the same. In my book clear, open and honest communication is absolutely key. In addition if staff feel able to communicate openly with managers and colleagues about errors then the organisation is then able to learn from these events rather than people not being able to be open about all aspects of the event…When learning takes place then adverse events are reduced.
How important is it to understand and acknowledge the root cause of an adverse event?
Identifying root causes is the key to preventing similar recurrences and when we have identified them every attempt should be made to put in place the necessary changes to minimise recurrence of an adverse incident. For some incidents it will simply not be possible to identify a Root Cause. It is, however, always possible to identify some lessons learnt which may affect how people behave in the future.
What do you see as the major challenge you will be facing in your role over the next 12 months?
The NHS in the UK is in the middle of a massive health evolution which will Increase GPs’ powers to commission services, establish an independent NHS Board and scrap Strategic Health Authorities, which is the type of organization I work in. So I guess the first challenge for me personally is to make sure I have a job in the brave new world; hopefully one where I can continue to influence perceptions of patient safety and encourage a culture where blame has to take a seat at the back of the learning bus!
Finally, what would be your top tip for encouraging a culture of open disclosure and reporting within a hospital?
Central to achieving an open, and therefore safer culture, is clear and honest communication between the various strata of an organisation. If staff can see that when care and treatment goes wrong because a genuine error has been made, their colleagues are treated fairly that should encourage and foster a culture where it’s OK to speak out without fear of reprisal. The subsequent investigation into the error must demonstrate a serious attempt to discover what within the organisational policies, procedures and behaviours needs to be changed to prevent systems from continuing to be unsafe and then the implementation of those changes must be encouraged from the highest level.
Looking forward to your comments.