(GAWANDE, A. COMPLICATIONS. PROFILE BOOKS LTD, HOLT METROPOLITAN, 2002 AND PICADOR USA, APRIL 2003. REPRODUCED WITH PERMISSION)

Although there is a certain amount of work in industry on safety behaviours and attitudes, comparatively little attention has been paid in the patient safety movement to the precise ways in which individuals, whether singly or in teams, can contribute to safer healthcare. People partly create safety by being conscientious, disciplined and following rules; however, they also create safety recognizing when one must think beyond standard procedures. Delivering safe, high-quality care is an interplay between disciplined, regulated behaviour and necessary adaptation and flexibility, considered in the following chapter. In this chapter, we consider the vexed issue of procedures in healthcare, why people often do not follow them and what might be done about it. The term ‘procedures in healthcare’ can encompass everything from giving an injection to complex surgery; in this chapter however, we are concerned with the basic rules, procedures and guidelines that govern clinical practice and behaviour.

Creating safety by following rules and procedures

Clinical work is founded on tried and tested ways of diagnosing and treating patients; being willing to follow procedures is fundamental to being a good clinician. Running an outpatient clinic for chronic asthmatics or diabetics, for instance, while still requiring much clinical acumen, requires good organization, good communication and reliable information technology delivering tried and tested, evidence based care. Much flexibility in healthcare stems not from necessary adaptation to changing circumstances, but from unnecessary, casual and inappropriate departure from good clinical practice. One way in which people create safety, therefore, is observing rules and by boring, conscientious following of standard procedures.

Protocols and guidelines for clinical care come in various forms. Most are disease centred and describe the procedures for the treatment of a particular condition in a particular context, such as the management of acute asthma in emergency departments or the management of diabetes in primary care. Clinical guidelines are ‘systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific circumstances’ (Foy, Grimshaw and Eccles, 2001). Previously derided by some as ‘cookbook medicine’, they are increasingly both accepted and embedded in formal decision support systems, care pathways and in national frameworks and targets. In these situations the protocol provides guidance, but there is an expectation that the standard procedures may always be modified according to the judgement of the clinician and the preferences of the patient. There will always be occasions when guidelines cannot or should not be followed; for instance, patients with multiple conditions and problems cannot easily be treated according to strict guidelines or the patient themselves may simply decide against a particular course of action.

In this chapter however, we are mainly concerned with protocols that define a standard clinical procedure for a routine task which, broadly speaking, should be carried out in a standardized manner; some variation may be expected for skilled tasks when the patient is a child or requires special care of some kind. Protocols for routine tasks are standardized and specified precisely because variation is thought to be at the very least unnecessary and, on some occasions at least, positively dangerous. Protocols of this kind are equivalent to the safety rules of other industries, defined ways of behaving which are intended to either improve safety or achieve a required level of safety (Hale and Swuste, 1998). Examples in healthcare include: checking equipment; washing your hands; not prescribing dangerous drugs when you are not authorized to; following the procedures when giving intravenous drugs; and routinely checking the identity of a patient. Such standard routines and procedures are the bedrock of a safe organization.

Breaking the rules and bucking the system

Why don’t people follow procedures? This was the despairing, indeed anguished, question put to me by a Director of Nursing after she had reviewed yet another case inwhich blatant disregard for the rules put a patient at serious risk. A review of the case showed marked lapses from basic procedures, seemingly for no good reason and the nurse in question was disciplined. Are these isolated incidents or are procedures often disregarded? Recall that James Reason speaks of ‘routine’ violations, implying that they are by no means uncommon. Routine and frequent violations? It seems incredible, until one begins to look more closely at the way human beings react and adapt to organizational policies and rules.

Fiona Moss is a chest physician and, for 10years, editor of Quality and Safety in Healthcare. In her last editorial for the journal, she chose to focus on an intractable issue that she sees as fundamental to improving the safety of healthcare, which is the fact that clinicians, by which in this instance she meant doctors, routinely break rules and ignore basic and reasonable organizational procedures and practices. As Moss puts it, there is a ‘chasm between organizational intention and individual action’ (Moss, 2004). Recall the death of David James described in Chapter 8, in which several staff departed from standard procedures, and then consider this paragraph:

Learning to buck the system is a frequent early learning experience for many doctors. For example, hospitals in the UK do not allow house officers to prescribe or administer cytotoxic chemotherapy. Although this ‘organizational rule’ has been in force for several years, we sometimes find that it has been broken. This usually happens at night, when a patient has not been given chemotherapy; the person who should give it is no longer on duty and the ‘covering’ doctor is called. Although this very inexperienced doctor and the nurse may both be aware that the doctor should not give the chemotherapy, neither perceives any real danger as the action needed is simply to attach an infusion bag to an already sited drip; both are concerned that the patient get the treatment and so the treatment is given. An organizational rule is broken. Nothing happens, no one knows. A culture that ignores the system of the delivery of care is enforced and the system becomes a little more dangerous.
(REPRODUCED FROM QUALITY & SAFETY IN HEALTH CARE, FIONA MOSS. “THE CLINICIAN, THE PATIENTAND THE ORGANISATION: A CRUCIALTHREE SIDED RELATIONSHIP”. 13, NO. 6, [406–407], 2004, WITH PERMISSION FROM BMJ PUBLISHING GROUP LTD.)

Notice first that there are many plausible reasons for breaking this rule. The patient needs the treatment and it would probably be time consuming to call another doctor with the authority to administer the treatment. The other doctor may in any case be off site or dealing with an emergency elsewhere; there may be good reason for breaking the rule on at least some occasions. But, in healthcare, the fact that it is sometimes necessary to think beyond rules very easily shades, by sleight of hand, into simply ignoring rules, because it is inconvenient for some reason. Once ignoring rules is socially, if not organizationally, sanctioned, the system becomes a little more dangerous, then more dangerous still, and so on until there is a major disaster. Within healthcare organizations, there are some rules which are never broken, others more on the margins, and some which are routinely flouted. These shifts in what is acceptable are known as migrations, in the sense that an individual or a team steadily drifts from behaviour that is, if not optimal, at least reasonable in the circumstances towards serious violations of procedures and behaviour that are frankly dangerous (Polet, Vanderhaegen and Amalberti, 2003; Amalberti et al., 2006).

Hand washing

Hand washing is an example of a rule that is routinely flouted; studies have found that average levels of compliance have varied from 16 to 81% (Pittet, 2001); compliance is probably higher in environments such as the operating theatre where the routine of getting scrubbed is solidly embedded. The causes of infection are undoubtedly complex and there are various routes of transmission. However, contamination through hand contact is a major source and hand hygiene a major weapon in the fight against infection (Burke, 2003).In spite of this, it has proved extraordinarily difficult to persuade healthcare workers to wash their hands.

The history of research into hand washing was for a long time a litany of failure, in the sense that most interventions had shown only small or transient effects; however, it was coupled with a steadily increasing sophistication in understanding the many factors that influence this behaviour and of the need for multifaceted interventions (Larson et al., 1997). Previous interventions to change clinicians’ behaviour had included education, feedback, financial rewards and penalties, and administrative changes. The lack of washing facilities at the patient’s bedside, skin problems through frequent washing and shortage of time were major barriers to hand washing for busy clinicians. Didier Pittet and colleagues (2000) solved these latter problems by introducing a fast bedside procedure of hand disinfection with an alcohol based rub. In a four-year intervention in the University of Geneva hospitals, they improved compliance from 48 to 66%; in the same period the prevalence of nosocomial infection reduced from 16.9 to 9.8% and the transmission rates of MRSA halved. The intervention involved a massive and continuing educational campaign, regular surveys and observations and the backing and involvement of all professional groups at all levels of the hospital. Compliance increased most markedly for nurses and nursing assistants but they were at a loss to explain, or at least would not publicly state, why compliance remained poor amongst doctors. There is now considerable political and regulatory pressure in many countries for improvements in both rates of nosocomial infection and hand hygiene, and major campaigns to replicate the improvements demonstrated in Geneva across the world (Pittet et al., 2005).

Understanding deviations from procedures

Are clinical staff particularly poor at following procedures compared with staff in other safety-critical industries? Healthcare is possibly more lax, but certainly not unique. Human beings never fully comply with rules and deviation from procedures occurs in all industrial systems, even those regarded as extremely safe. For instance, an extensive observational study of aircrews’ deviations from procedures showed that ‘intentional non-compliance’ represented 45% of all errors and violations, but only 6% of these affected the flight in any adverse way (Helmreich, 2000). To understand why this is, we will examine studies of violations in two contrasting settings.

Rebecca Lawton (1998) is an enterprising researcher who qualified as a railway shunter while investigating safety on the railways. Being a shunter involves ensuring the safe movement of rolling stock in sidings, depots and stations and coupling and uncoupling of trucks and engines; if a shunter is trapped between two trucks or hit by a train, the chances of survival are slim. At the time of her study, the British railways network had 2000 shunters; an average of two shunters were killed each year, with investigations commonly revealing violations of basic safety procedures. Being a railway shunter is an extraordinarily dangerous occupation providing, you would have thought, every incentive for following safety procedures.

Interviews established that the shunters were well aware that safety procedures were often bypassed and could estimate frequencies for them. For instance:

• Even though he has lost sight of the shunter, the driver does not stop during a movement (High risk, high frequency).
  
• The shunter works without wearing the high visibility clothing provided (Low risk, high frequency).
  
• The shunter remains in between the trucks and asks the driver to ease up (High risk, low frequency).
  
• The shunter fails to look both ways before crossing the line and does not take extra care when stepping out from behind a truck (High risk, high frequency).

The main study asked shunters to endorse different reasons for the violations of safety rules, with revealing results. The reasons (Table 16.1) fall into three basic categories, reflecting the earlier discussion of the psychological classification of error and violation (Reason, 1990). Some are not strictly violations in the strict sense of the word, but arise more through lack of understanding or inexperience; in these circumstances, there is no sharp dividing line between errors and violations. A second group were labelled ‘exceptional violations’, when rules are bent in order to find a solution to an unusual situation. Finally, there are ‘routine violations’, which are frequent and considered low risk, often justified by the belief that the shunter is sufficiently experienced and skilful to cut corners. The same belief, or rather delusion, underlies a lot of dangerous driving (McKenna and Horswill, 2006).

Look again at Table 16.1 and substitute nurse, doctor, pharmacist or psychologist for shunter.Imagine your own working environment and the routine tasks you should carry out, but may not. Does this list of reasons seem familiar? A similar study of violations was carried out with anaesthetists using common scenarios, such as the ones below to elicit the reasons for potential violations:

Table 16.1 Railway shunters’ reasons for violations

Reprinted from Safety Science, Rebecca Lawton. Not working to rule: ‘‘Understanding procedural violations at work’’. 28, no. 2, [199-211], 2004, with permission from Elsevier.

You have an elective surgery list tomorrow morning. It is a routine list which you have done often before. Most patients on the list are ASA I–II. However, from time to time the list has thrown up unusually difficult cases where patients have been ASA III–IV. The list you have just completed has over run by an hour. You decide not to visit the patients but to speak to them the following morning in the operating theatre reception.

When you arrive at the list and enter the induction room there is no one about. The operating list is there and you note that a new case has been added to the end of the list. You cast a quick eye over the anaesthetic equipment in the operating theatre and everything appears to be normal. You decide not todoa ‘cockpit’ equipment check so that you may use the time to check up on the new patient.
(BEATTY AND BEATTY, 2004)

The researchers used a questionnaire examining anaesthetists’ views of the factors that would influence the likelihood of following, or not following, these standard procedures. Three classes of belief were examined: beliefs about the consequences of the act; normative beliefs which are an assessment of the views and influence of other relevant people; and beliefs about control over the situation, factors such as time and resources which influence what is manageable in the circumstances (Table 16.2). Clinical reasons, such as preventing incidents, a vulnerable patient and ASA status were not surprisingly very important influences on behaviour. However, most striking was that equal importance was given to normative influences such as the views of colleagues, friends and teachers. From this pen and paper exercise, one cannot really say that these factors determine whether an anaesthetist checks their equipment or not, but it does suggest that the social environment and the cultural norms play an important role in understanding violations. The ‘way we do things round here’ includes basic clinical procedures, as well as less tangible attitudes and values.

Table 16.2 Influences on anaesthetists’ willingness to violate safety rules

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