New groundbreaking report examines 'How safe are clinical systems?'

The first UK study that examines the reliability of healthcare systems and the impact of poor reliability has been published today. 

The Health Foundation’s report 'How safe are clinical systems?' examines the extent, type and causes of failures in reliability in different healthcare systems.

'How safe are clinical systems?' is a groundbreaking report as this is the first study to analyse reliability in healthcare systems in this manner. The research was carried out by Bryony Dean-Franklin and team from Imperial College and Warwick Medical School.

This report is part of the Health Foundation’s work to help healthcare organisations improve the quality of services they offer and provides evidence of the extent to which important clinical systems and processes fail, and the potential these failings have to harm patients. 

Stephen Thornton, Chief Executive of the Health Foundation said, ‘We cannot continue to treat the levels of risk identified in this report as acceptable or inevitable. More research is needed to investigate the underlying factors affecting the reliability of healthcare systems and processes, and the impact on patient safety.  We encourage NHS leaders and practitioners to use these findings to consider how to improve reliability in their own organisations’.

The primary research was conducted in seven NHS organisations and the results of the study identify the variation in the reliability of five key healthcare systems and processes:

• availability of information when making clinical decisions
• prescribing
• handover
• availability of equipment in operating theatres
• availability of equipment for inserting intravenous lines.

The key findings from the report are:

• Failures in reliability pose a real risk to patient safety. We found 15% of outpatient appointments at the study sites were affected by missing clinical information.
• Important clinical systems and processes are unreliable. The four clinical systems for which reliability could be measured had an average failure rate of 13%-19%.
• There are wide variations in reliability. Different organisations varied significantly in their reliability on issues such as faulty or missing equipment.
• Unreliability is the result of common factors. Common factors that affected reliability included a lack of feedback mechanisms and poor communication.
• It is possible to create highly reliable systems. The variation between and within organisations suggests that it’s possible to create systems that are more reliable.

The report also states ideas that could lead to improvement for reliability in systems:

• Improving feedback mechanisms.  Better feedback to doctors about their prescribing errors.
• Standardisation. A standard format for handover is likely to ensure that all essential items are handed over.
• Improving communication. Better communication between theatre staff and sterilisation units would help the units understand what staff need.
• Developing a culture of challenge. Healthcare staff needs to be encouraged to challenge poor reliability, and to see that their suggestions are welcomed and result in change.
• Encouraging a sense of ownership. Individuals tend to blame others or the systems rather than seeing themselves as being able to improve reliability.

This study also supports the Health Foundation’s Safer Clinical Systems programme which tests and demonstrates ways to improve healthcare systems or processes to systematically improve patient safety.