Creating a Just Culture
In this article, Prof Chris Frerk, Consultant Anaesthetist at Northampton General Hospital and trustee of the Clinical Human Factors Group explains what to do when things don’t go according to plan and we can learn from airway events.
When something goes wrong it is a natural reaction for people to look for someone to blame. When two cars crash we want to know who was to blame. We know that this helps to decide who will pay for the damage. But blaming someone does not help them be a better driver. Helping people to learn to be better after things go wrong is a special skill.
Sometimes things go wrong during airway management. It does not go as well as it could. It happens to young doctors. It happens to professors. It can happen to anyone. It has happened to me. It will happen to you.
The most important thing to do is to look after the patient as well as you can on that day. The next most important thing to do is to learn from what happened. If we can learn, then things will go wrong less often.
For us to learn, four things need to happen:
• We need to tell our colleagues when things have not gone as we hoped
• Our colleagues need to help us understand why it happened
• We need to work out what we can change so that things will go better in future
• We need to make that change
We can learn in the operating theatre. Our teacher will help us improve our skills. We can learn in the coffee room, talking with somebody we trust. We can learn in morbidity and mortality meetings with the whole department.
Some people are better at helping us learn than others. Sometimes, even people who are very good at doing something are not very good teachers.
Think about some of your best teachers. Think about the ones who helped you learn and improve the most. What was it about them that made them so good?
Good teachers do not tell us off because we do not know something. They help us to understand and they help us to remember. Good teachers do not tell us off because we cannot do something, they show us how to do it and they help us to become better. But even knowledgeable and skillful doctors don’t always get everything right. Working out why even the best doctors make mistakes is difficult. The best teachers work out why this happens and help us make it better.
Here are some of the things that the best teachers think about. Watch your favourite teachers do these things. Practice doing the things they do. You can become a great teacher. You can help other people learn when things don’t go as well as they could.
• Do not criticise someone just because something went wrong. They know something went wrong. They want to learn. If you criticise them they will not tell anyone next time something goes wrong.
• Do not say “I would not have done that”. Try to find out why they did what they did. Ask yourself “Why did that seem the right thing to do?”.
• If someone tells you they made a mistake, make sure that they are OK.
• When they tell you about what went wrong, make sure you understand what happened. Ask them if you can help.
• Look at the equipment that is available in the hospital. Sometimes the reason things go wrong is because the doctor did not have the correct equipment. We should not blame a member of staff for a failed intubation if the correct equipment is not available.
• Look at the training that the hospital provides.
• We should not blame a doctor for something that has gone wrong if there is no training programme.
• Look at all the systems that the hospital has in place.
We should not blame a doctor for something that has gone wrong if the hospital notes are not available. We should not blame a doctor for something that has gone wrong if they are not given enough time to examine patients properly. We should not blame a doctor for something that has gone wrong if the team is short staffed.
The best teachers think about all these things when they are helping us learn. We should think about all these things when we hear that a healthcare practicioner had difficulty with a patients airway.
We need to be as good at airway management as we can be. We need to train hard and listen to our teachers. But even well trained professionals make mistakes. When we make mistakes we need to look at all the systems around us and make improvements to them.
We need the right training. We need the right equipment. We need the right medications. We need to have enough time to do our jobs carefully. We need the right team of people working with us. We need to be able to get help when things are difficult. We need to have breaks for lunch. We need to get enough sleep.
Serious complications caused by problems with the airway are rare. But when something does go wrong, we should not blame ourselves straight away. We definitely should not blame someone else. We should look at all the things we have talked about and help the hospital to improve them.
Do you agree with Prof Frerk that this is how we should be learning from mistakes? Is this how mistakes with are dealt with in your institution or do you feel that the blame culture is still too prominent? Discuss your experiences with your fellow learners in the forum.