NHS trusts not open enough about serious mistakes

Survey finds that most trusts have formal policies in place, but these are rarely fully enacted.

Adapted from a news release issued by BMJ Quality & Safety

Despite widespread recognition in NHS trusts of the importance of being open about mistakes that have been made, the way in which serious patient safety incidents are handled still leaves much to be desired, indicates research published online in BMJ Quality & Safety.

The researchers base their conclusions on the results of an online survey sent to patient safety managers, responsible for the “Being Open” policy, in all 386 NHS trusts in England, between November 2010 and February 2011.

“Being Open,” which was devised by the now defunct National Patient Safety Agency, explains how trusts can best create an open and honest environment for patients, relatives and staff, so that serious incidents are dealt with promptly and comprehensively, and all parties involved are properly supported in the aftermath.

This guidance, which was originally issued in 2005, was reiussed in 2009, after it was felt that little notice had been taken of it.

The survey aimed to find out the extent to which policies were in place and used; what hindered openness; and what types of support for patients, their families, and staff were available. The research was conducted by the Centre for Patient Safety and Service Quality (CPSSQ) at Imperial College London.

In all, 209 patient safety managers responded, giving a response rate of 54 per cent.

Virtually all respondents (98 per cent) were familiar with the “Being Open” guidance. But one in 10 trusts had no formal, board-approved policy on open disclosure in place.

Less than half the respondents (44 per cent) said the guidance was followed all the time.

Only 38 per cent reported a substantial increase in open discussions about patient safety incidents over the preceding two years; and almost one in five had open discussions with patients and families, half or less than half of the time.

Two thirds of discussions with families took place up to six weeks after the investigation had been completed, suggesting that many patients and their families may be waiting up to a year without any clear explanation of what had gone wrong, say the authors. Managers tended to outnumber doctors at these discussions.

And incidents that led to a full recovery were discussed significantly less often than those leading to death or disability, possibly because organisations are more likely to be open when they expect patients to make a formal complaint, suggest the authors.

Managers most frequently cited fear of blame, litigation and the family’s reactions, along with concerns about how doctors would feel about being accused of malpractice as barriers to openness. While managers clearly recognised that support for staff in the wake of an incident was extremely important, it was not always available. Training, in particular, was only available less than half the time.

One respondent commented: “There is a general fear of admitting liability and a lack of understanding particularly around disclosure and legal processes. Staff generally want to be open but the problems in the NHS and the prevailing culture across the NHS do not help. People are worried that they may lose their jobs and therefore income and are worried how they will be perceived or judged or that they will be made scapegoats for institutional errors, shortcomings etc.”

But informing patients about what happened, and how, is key to maintaining trust, say the authors.

Anna Pinto, first author of the study, said: “Our research suggests that there is high awareness among NHS patient safety managers of the importance of being more open with patients, but that progress is slow and that some trusts have simply failed to recognise the importance of this issue. The findings highlight the need for NHS Trusts to look closely into the ways in which they manage the aftermath of patient safety incidents and to ensure that sensitive support mechanisms are in place or patients, families and staff.”

The study was supported by funding from the Health Foundation. The CPSSQ is a partnership between Imperial College Healthcare NHS Trust and Imperial College London funded by the National Institute for Health Research.

Reference:

A Pinto et al. ‘Managing the after effects of serious patient safety incidents in the NHS: an online survey study’ BMJ Qual Saf doi:10.1136/bmjqs-2012-000826