A System of Safety

The role of the laboratory in patient safety tends to be overlooked. Why? Partly because so many people are unaware of the depth of the lab’s involvement in patient care (which is linked to the fact that laboratory medicine professionals are often invisible contributors to the patient experience); and partly because not everyone takes a “systems thinking” view of patient safety that includes every step of the diagnostic and management process. Pathologists and laboratory medicine professionals are key players in identifying errors, understanding their causes, preventing them from affecting patient care, and developing methods that reduce the risk of future mistakes. Berenice Lopez  is RCPath Clinical Director for Quality and Safety, Associate Medical Director for Quality and Safety, and Consultant Chemical Pathologist at the Norfolk and Norwich University Hospital. Here, she explains what laboratorians can do to contribute positively to safe and effective patient care.

What does patient safety mean to you as a pathologist?

A huge amount of work has been done over the decades to address safety issues in pathology, but I think it’s fair to say that this work has mainly focused on the standardization of systems and processes – including the development and assessment of standards. Although this valuable work has raised the profile of patient safety in pathology, it takes a traditional approach – “safety 1” – and engenders a widespread belief in the efficacy of procedures, with an emphasis on compliance. Core assumptions include:

• that work can be completely analyzed and prescribed
• that people at the sharp end “work as imagined”
• that acceptable and unacceptable outcomes result from different modes of functioning – either correct or failing
• that when things go wrong, it’s because of identifiable failures or malfunctions of specific components – technology, people, the organization – and the root causes can be found, corrected, and prevented

In “safety 1,” people tend to be viewed predominantly as a liability or hazard, largely because they are the most variable of the components. Safety is defined by its opposite – by what happens when it’s absent, rather than when it’s present. To move forward, we need to think much more widely about safety and how we approach it. A key part of this is acknowledging the increasing complexity of healthcare – and the value of people. Patient safety in pathology is not just about standards, corrective and preventive action, and incident reporting, although these things are valuable and important. It’s also about asking why things go reasonably well most of the time and what we can learn from that, too – the “safety 2” approach.

“Safety 2” recognizes that, although rules and regulations are necessary to guide “work as done,” performance adjustments, performance variability, and trade-offs are not violations or non-compliance; they are unavoidable – and vital to system safety. It is people who make our imperfect systems function by adjusting their work to the conditions. Safety cannot be managed by imposing constraints on normal work.

How do you contribute to patient safety?

Focusing on my role as a consultant in laboratory medicine, I contribute to patient safety in multiple ways. I play a key role in error surveillance, acting as the final safety net to intercept errors before they reach patients. Another role is error prevention; for example, by coordinating and overseeing complex requests in which the likelihood of a misstep is higher. I would say that one of my most important roles as a consultant is supporting a strong safety culture in my workplace, including the importance of teamwork, staff psychological safety and wellbeing, and support for learning. It is an approach that demands a mindset of openness, trust, and fairness.

A classic example from my own experience is the error that arises from a process deviation in the laboratory. An immediate reaction may be to shake one’s head upon hearing that policy was not followed – but staff are usually trying their best to accomplish an end goal in difficult circumstances. If they need a workaround to be successful, they will find one. This creative approach should be encouraged because, when you identify where it is occurring to good effect, it can be built into future processes to make them more effective in the future. And that’s one of the reasons why a no-blame culture is so important. How can we develop if we’re afraid to think outside the box?

What advice do you have for other pathologists and laboratory medicine professionals?

Reflect on your mindset and assumptions about your colleagues, especially when work is not completed as you imagined. Be careful with your language; avoid judgmental or blaming phrases, such as “you should have,” “you failed to,” or “you neglected to.” Instead, get curious about how work is actually done. What is documented in the standard operating protocol (SOP)? How is the environment set up? What are the external distracting factors? Listen to staff articulate what they think the problems are. Are certain parts of the process hard to perform? Why? Do they need “tribal knowledge” to actually get a process to work, circumventing the SOP?

To improve safety, don’t just wait for something to go wrong and then react. Instead, try to understand what actually takes place in situations where nothing out of the ordinary seems to happen. Identify what adjustments result in success and try to learn from them. This proactive approach is at least as important as finding the cause of and learning from an adverse event. We cannot make sure things go right just by trying to prevent them from going wrong. We also need to know how they go right.

Take a step back to think holistically about outcomes, work, and systems. Instead of first digging deep into an incident to identify the root cause, go up and out into the system as a whole, switching perspectives (stakeholders and situations). Zoom out before you zoom in. A “systems thinking” approach to safety is important (see Figure 1); trying to understand how a system functions by breaking it down to its constituent parts and interpreting it using linear “cause and effect” thinking risks stripping out vital context for understanding and intervention. Ignorance of systems leads to interventions based on poor understanding, which may be ineffective, counterproductive, or even have unintended negative consequences. Even the safest and most efficient individual parts, if designed and managed separately, will not yield a smoothly functioning system. We must take a holistic view.

How can those in the laboratory help to improve patient safety?

Get out from behind your desk and engage with patients. It is vital to use the experiences, ideas, and concerns of patients, their families, and carers to drive improvement in pathology. Undoubtedly, this approach can potentially be more challenging for us because we are often not directly patient-facing, but we nonetheless need to put in the effort to make our systems work well for our patients. And this is especially true of those who are highly reliant on our test results for the long-term management of their condition.

Finally, be as compassionate with yourself as you are with your team. Errors are inevitable for even the most highly skilled, experienced, and motivated among us. We are only human and we work in a system that has a powerful effect on our performance – for good and for bad.