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When things go badly wrong

2 September, 2019

Author: Lynda Johnson, Maria Murray and Chris Woodgate

As radiographers we are all autonomous practitioners. We are not answerable for the actions and attitudes of others, until that is, there is possibility of harm. We are personally accountable but we have collective responsibility. This is what professional registration means. It’s how it helps prevent harm.

It’s encouraging and heart-warming to read about success stories, best practice and getting it right first time. It’s a lot less comfortable to talk about getting it wrong.

Interestingly, the stories SCoR publish about Health and Care Professions Council fitness to practise investigations always get a lot of interest. Is this professional curiosity, or fear that one day it might be us? This year’s HSJ Patient Safety Congress was a stark and emotional reminder of the consequences of getting it wrong.

Is it enough to come to work and just do enough to make sure we don’t mess up? Do we keep our heads down and concentrate on the microcosm of our own day and the interactions we have as individuals?  Or is there more to being a registered healthcare professional?

Several things have raised alarm bells in recent months, both at the Safety Congress and from day to day conversations.

The pressures of the job

We don’t listen to patients or their families and carers enough; we don’t always understand their needs. We listen to patients retrospectively; we get their feedback but we don’t ask for their input.

We forget about 'no decision about me without me'. There isn’t enough time to do things properly; departmental operating procedures are not always followed. Adequate training has not happened because there’s not enough time or staff to do it; competencies have not been signed.

We are planning to lose a role that used to be fundamental to safe practice, not as a patient improvement measure but because we don’t have enough staff. Shifts have got longer. Shifts have got shorter but now we’re being asked to work overtime to make up the shortfall.

We are sending patients with more complex needs to outsourced services. Error reporting rates have risen but no one seems to be doing anything about it. Investigations into errors and near misses have become tick box exercises with little opportunity for learning.

There are worsening retention and recruitment problems. Executives, leaders and managers maintain they are not aware of any concerns being raised. Everything is fine.

This is all reminiscent of something, isn’t it? The Francis report into the events at Mid-Staffordshire NHS Trust found evidence of systemic failure to deliver proper care and systemic issues which did not receive either urgent or effective attention.

Trust and judgement

The SCoR responded to this with professional guidance to employers to put principles in place that safeguard patients and empower staff to speak up. One of these principles was “Employ leaders who trust the clinical judgment of staff, allowing them space to exercise their judgment."

It could be argued that the reciprocal of this also applies. Employ leaders who staff can trust to effectively exercise their judgement. An environment which promotes respect and civility between employees at all levels will be a safer one. Senior NHS staff should encourage others to report their concerns, not chastise them for doing so.

Radiography managers today have an immensely challenging task and each has their own strategy. The overarching message from the HSJ Patient Safety Congress is that whatever we are doing and however we are doing it, we need to create a culture of psychological safety.

Speaking up

There was a thread that ran through each of the heart wrenching patient stories. People were afraid to speak up. They were afraid to speak up when they might have prevented harm and they were afraid to speak up after things had gone wrong. They were afraid of being blamed, or being labelled as trouble makers.

The NHS Patient Safety Strategy was launched during the Congress. It talks about a 'just' (no blame) culture and safer systems. During the strategy consultation process, stakeholders reported a prevalence of fear across the NHS, frustrating attempts to develop just cultures. Interestingly, several presentations during the Congress highlighted how the same fear of blame has a similar impact on safety systems in industry.

To support services to consistently deliver safe and high standards of care, the SCoR and the Royal College of Radiologists have jointly developed the Quality Standard for Imaging, which is designed to be patient focussed, covering all the functions and systems of a whole diagnostic and interventional imaging service whilst addressing quality in delivery. All the key points that the Francis report addressed.

There are specific sections through the whole standard which could address the issues of concern and these can be found in the Leadership & Management domain (LM1 & LM2), the Facilities, Resources & Workforce domain (FR4 & 5), as well as the Patient Experience & Safety domains.

Using evidence and audit of these areas can help managers and staff develop business cases, or a portfolio of concern to senior management to help address service and individual unease.

The College of Radiographers led a crucial project on behalf of the Clinical Imaging Board (CIB) to standardise and further learning from error reporting. Available on the CIB website, Learning from ionising radiation dose errors, adverse events and near misses in UK clinical imaging departments, provides a user guide, reporting template and coding taxonomy for all diagnostic radiography services to use. It has been adopted by the CQC in England as a means of identifying patterns of reportable errors and disseminating learning opportunities nationally.

We should not forget to celebrate services striving against incredible odds to deliver safe care; there are many succeeding through collaboration and innovation. Perhaps we don’t shout enough about the good stuff because we’re too busy doing it. But if you recognise any of the above warning signs in your own service, please don’t stay quiet. Speak up, share your concerns with someone.

The Society of Radiographers' Code of Professional Conduct, paragraph 4.2, states: ‘You must report any concerns you have about malpractice or patient safety to your manager or other senior professional, ensuring that you follow up such a report where appropriate’.

If you have an accredited SoR Rep you can speak to them for advice. The SoR will support members who raise concerns but the SoR cannot raise concerns on behalf of members. If you do not feel you have an appropriate person within your service to whom you can raise your concerns, speak to your local Freedom to Speak Up Guardian or Whistleblowing Champion in Scottish Health Boards. Very useful CPD is the eLfH Freedom to Speak Up programme.

We are all working towards the same end: the safe and effective delivery of the highest standards of care. We must not lose sight of this in our attempts to do more for less. We must endeavour to make things better for our patients.

Let’s support and trust each other to be open and share everything we do. As a profession we will flourish, our patients will be safer, and our interactions as human beings will be richer.

Lynda Johnson is a Society professional officer for clinical imaging. Maria Murray is the SoR officer for professional issues in Scotland and lead officer for radiation protection. Chris Woodgate is the quality improvement partner for the Quality Standard for Imaging.

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