Air accident experts create safety course for NHS

Cranfield University is to run a new course for NHS staff involved in investigations to improve safety in hospitals. The new week-long intensive course for staff in NHS trusts will be run in partnership with the charity Baby Lifeline. Commencing in January 2021, it will give students a basic grounding in the science of investigation and using real-life actors and a maternity-based scenario, helping participants to get to the real causes of what went wrong.

It is part of a growing effort to install a safety science approach to avoidable harm in the NHS, with the service increasingly looking to other industries to adopt new approaches based on the science of human factors and just culture. Craig Cattell, lecturer in safety and accident investigation, said: “We want to introduce  a good knowledge of the investigative process at a practitioner level. It can often be the realm of gifted amateurs, where what we aim to do is to inject a more scientific approach and give them the skills that mean they can provide a better quality of report and actually get away from blame, to learn the lessons from any safety events that have happened.” He said investigations in smaller, less severe accidents can help identify risks that, if acted upon sooner, can prevent larger mistakes later: “It’s about catching the low hanging fruit quickly and, ultimately, creating a safer environment.” He continued: “Often the investigations that are done in many organisations that don’t have  this sort of safety culture often look for someone to blame, someone whose fault it was.

That really isn’t what the actual investigation process is about. It’s about everyone being open and honest, putting their cards on the table and saying look, things went wrong. We generally find that in all instances, errors are systemic and the failures that are there will be multiple and minor.” Cranfield has been training air, maritime and rail safety investigators for more than 40 years, and has an international reputation for its award-winning teaching, research and consultancy in transportation safety management, human factors, airworthiness and accident investigation. Using the procedures employed in investigating air and maritime accidents, the training will to help improve the way the health service learns from patient safety incidents. James Titcombe, from Baby Lifeline, whose son Joshua died as a result of safety errors in 2008, said: “The point at which something goes wrong in healthcare is critical for everyone involved. Carrying out an effective incident investigation is a specialist task that requires a high level of knowledge and skills, yet too often healthcare organisations delegate such investigations to clinical staff with little training or support. “Time and time again, major inquiries and reports highlight the need to improve how healthcare organisations respond and learn from adverse events – yet there is still no standardised training to support healthcare staff who do this vital work.”
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