While the knowledge that poor systems can cause harm is not new, this report provides groundbreaking evidence of the extent to which important clinical systems and processes fail, and the potential these failings have to harm patients. The results of this study, covering seven NHS organisations, identify the variation in the reliability of five key healthcare systems and processes.

These processes are:

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

The research, led by Professor Bryony Dean-Franklin, was conducted by The Centre for Patient Safety and Service Quality (CPSSQ) at Imperial College, and Warwick Clinical Systems Improvement (CSI), University of Warwick.

Key findings

  • Failures in reliability pose a real risk to patient safety. For example, we found 15% of outpatient appointments at our 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 is possible to create systems that are more reliable.

Ideas for improvement

  • Improving feedback mechanisms. For example, better feedback to doctors about their prescribing errors.
  • Standardisation. For example, a standard format for handover is likely to ensure that all essential items are handed over.
  • Improving communication. For example, better communication between theatre staff and sterilisation units would help the units understand what staff need.
  • Developing a culture of challenge. Healthcare staff need to be encouraged to challenge poor reliability, and also 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.

Further reading

Safer Clinical Systems

Developed as a five year phased programme, Safe Clinical Systems helps health care teams proactively identify potential safety breaches, enabling them to build better, safer health care systems.