Dr Raj Persaud FRCPsych Consultant Psychiatrist


Right back at the beginning of the World Cup, when we were all optimistic about the prospects (remember then?), an ominous harbinger that things may not go well occurred in the first England game. Our hapless goal keeper let the ball slip through his fingers, so snatching a draw from the jaws of victory. The media storm that subsequently broke over the head of poor Robert Green, reminded medical colleagues of a culture of ‘blame and punish’ approach to clinical error. Physicians commented at an anecdotal level that the same approach appears endemic in the NHS.


We therefore hit upon the idea of conducting a survey of UK doctors to investigate, in the midst of wall to wall opprobrium players were receiving, if this treatment did indeed ring any bells with attitude to mistakes in the NHS.


It was also notable how ineffective ‘blame and punish’ as an approach to blunder turned out to be in achieving the ‘goal’ (sorry) of lifting the World Cup. The current NHS standpoint to clinical error appears similarly misguided – little improvement appears apparent over time, and instead much grief is generated. The talented consider leaving the field because it just doesn’t seem worth it. Perhaps a misguided attitude to mishap in turn contributes to poor performance. The media and managers may gnash their teeth at supposed incompetence, but do they contribute to the problem with their own flawed outlook?


For example, because doctors are so afraid of owning up to mishap, these could get brushed under the carpet, and learning opportunities are therefore lost.


Our brief survey, conducted for a short period during the start of the World Cup, sought to take the temperature of doctors on their experiences and attitudes to the subject. It was notable from the outset that one or two dissenting voices couldn’t fathom why we might want to investigate the subject, as they seemed to believe it had all been done before. But then again, where would be without its dissenting voices?


If you type in the key word ‘error’ into Medline database back to 1950 and PsycInfo back to 1800, 111,862 hits come up. For the key words ‘clinical’ and ‘error’ combined, the number of papers drops dramatically to 18,246. And if you add the key word ‘NHS’ the number of papers tumbles out at 26.


Incidentally most of those 26 papers concern surveys of Medico-legal cases, while a further key category appeared to be nursing error.


Another way of surveying the literature would be to use as keyword or phrase, a famous method of approach to physician fault, one such is termed ‘Root Cause Analysis’ (RCA), and again only 76 papers came up in these databases, with such key terms in the title.


A recent comprehensive review of ‘Root Cause Analysis’ published in the academic journal Joint Commission Journal on Quality & Patient Safety in 2008 could only uncover 38 studies which were examples of RCA being deployed to investigate specific incidents. This review concludes that the literature on this approach to medical mistakes is ‘limited’.


So, here at HQ, we didn’t concur the subject has been ‘done to death’, and also, we couldn’t find any good examples of a comprehensive survey of UK doctors’ actual daily experiences of attitude to blunder, focusing on the psychological and managerial cultural aspects.


Some of the comments that respondents left as a result of taking part in the survey were also sobering.


‘There is no tangible driver in our acute trust to ensure that errors are discussed and lessons learned, other than the personal enthusiasm and professionalism of individual clinicians. Organisational motivation for effective clinical governance at this level appears to be absent. Surely this must change?’


Was one, which gives some idea of other comments, and another, which was particularly apposite given the original article on the subject, strove to examine links with the aviation industry when it comes to attitude to error:


‘I’m a doctor and I fly (professionally and for pleasure). I don’t report near misses at the hospital or fill up incident reports, because the fires of administrative hell would fall upon me. I know – it happened to me more than once.’


To turn first to the demography of our survey respondents – of the 75 members of who took part, 72% were Hospital based, 14% were GP based; 60% were senior doctors in hospital or GPs; 85% were from England and 64% were male.


47% strongly agreed there was a culture of blame and punish in the health service with 39% somewhat agreeing, while only 14% were neutral, disagreed or strongly disagreed. This result would be seen as an overwhelming endorsement that ‘blame and punish’ is what the vast majority of doctors’ experience.


An even more astonishing result occurred when we asked whether the approach to clinical error needed to ‘improve profoundly’ in the health service, with absolutely no one disagreeing, and only one doctor neutral on this point. 69% strongly agreed and 29% agreed.


When it comes to whether UK doctors feel they can easily discuss their mistakes with colleagues, only 10% strongly endorsed this position. 47% somewhat agreed with this, while a total of 43% were neutral, disagreed or strongly disagreed. One sign that we were moving toward a healthier attitude to mistakes is if this 10% figure was substantially higher. Surely patients would be safer if the vast majority of us could strongly endorse that we found it easy to discuss mistakes with colleagues?


This relatively prevalent ease of ability for doctors to discuss errors with colleagues might indicate that the problem with attitude to error doesn’t so much reside with doctors, but more with another area, or group of staff. This is because there seems to be a contrast with this result, and the overwhelming agreement that blame and punish is so prevalent plus that it’s also undesirable, given the earlier questions in the survey,


51% of UK doctors surveyed strongly agreed that NHS managers were treated more benignly, when it came to errors that harmed patients, than physicians, while 25% somewhat agreed. This sense of inequity can surely only be deeply corrosive in the relationship between doctors and managers.


68% of UK doctors surveyed believed that the way NHS managers’ errors are currently handled by the NHS has negative consequences for patient care – a figure achieved by adding up the even split in strongly agree and agree with this statement. Again it’s startling that two thirds of doctors consider the current discriminatory culture doesn’t just exist, but is a factor in adverse outcomes. A total of 85% of UK doctors surveyed either agreed, or strongly agreed, that doctors and managers should be treated the same when it comes to mistakes.


Less than a third appeared to have used the National Patient Safety Agency and only 20% agreed or strongly agreed that analogies with other industries like airlines were not relevant to approaches to clinical error. This indicates a thirst for novel perspectives, and a jaundiced or disheartened attitude to current facilities.


When asked to suggest other industries that deal with mistakes better than health care, of 35 responses to this question, 10 agreed with the introductory article that we had a lot to learn from aviation. Of course a bias might have been introduced by the very emphasis on aviation in that lead piece.


However, there were also some other intriguing answers, which the profession and the NHS might want to further consider. Diving, Construction, Formula 1, all featured, though the several respondents who put banking down, may have been being ironic? If they weren’t, could they send us some more thoughts on that one, as we all jointly suffer through the deficit?


Several mentioned the military (with the Chinese Army coming up for some reason), with this particularly interesting comment accompanying one suggestion:


Military – especially US and UK. They have a “flexibility” that they realise mistakes will happen but change the systems quickly to prevent more errors. There is no “perfect” system no matter how it is designed, so we must accept that and try to build on our errors so they do not happen again.


Several comments were that no specific industry was going to be suggested because it was very simply difficult to think of any area of human endeavour whose approach to error was not better than the health service!


The following gives a flavour of some of the more general comments left by respondents.


‘The problem with risk management from my experience is that no action is normally taken unless a disaster happens. There doesn’t seem to be any point in troubleshooting something because management is not interested in being proactive in averting disasters, despite incident reporting. However when the worst happens, it is always the clinician’s fault for making the mistake, and a scapegoat is often found.’


 ‘If you don’t make mistakes, you’re not seeing enough patients. Was told that by a wise old consultant, and it’s sadly very true. Too often, we are criticised by those either never, or no longer in clinical practice, or worse, managers and nurses with no conception of our role.’

‘We currently work in a climate where the sum total of errors and non-errors (an action which does not necessarily lead to harm) are increasingly highlighted by patients and the media. The handling of such and the “blame and punish” culture needs to adapt to this changing climate as physicians are currently struggling under the weight of this increasingly common threat. It is not a resistance to change or improvement on behalf of the physicians part but more a lack of appreciation of human error and the systems effect that is acknowledged and acted upon by such industries as the aviation industry.’


‘All doctors will make mistakes: we are human. Fortunately, the vast majority of these are minor and cause no patient harm, or are caught by backstopping (pharmacy prescribing checks, for example). So many go unreported either for the reason above, or because of the blame and punish culture, which makes everyone behave in a defensive way.’


We badly need to improve our handling of mistakes, because we keep making the same ones, blaming the individuals, and then continue on.’


Following the result of the World Cup, which was not known at the time the survey was conducted, the last comment seems to prophetically apply equally to healthcare, and the England Soccer Team.