With the recent publication of the new Patient Safety Strategy, the team at CASC have been updating our accredited Root Cause Analysis training and as part of that process we have been doing a fair bit of research. To cut a long story short, this led us to stumbling on a phrase that we have never heard before and very much like, which is ‘when you lose, don’t lose the lesson’. The origins of this are attributed to a range of people, but it appears as though the phrase was first said by the Dalai Lama!
In essence, the message is clear… when we lose or when things don’t go to plan, there are always lessons to learn that will help us in the future. The key question is, do we seize the opportunity and seek to learn? In many ways, the quote reminds us of another well-known statement that is relevant to all of us working in audit and improvement, ‘there is no failure, only feedback’. Now of course we have to be careful here. If we fail to care for a patient appropriately and mistakes are made that lead to the death of that patient, we cannot begin to suggest there has been no failure/s. However, the key point to make is that we must use bad experiences and failures to reflect, learn and make sure we are better next time. If we are not self-critical and choose not to use valuable feedback, then more fool us frankly!
Just over 20 years ago, at a time when NICE did not exist, I worked in primary care and was tasked with undertaking a countywide audit on repeat prescribing. This was no small challenge, with no agreed national or local guidelines in existence. Added to that, repeat prescribing is an important area of care with delays in medications and pills likely to: a) annoy patients, b) increase the likelihood of non-compliance, c) impact on patient well-being and d) raise the levels of unused medications. Getting repeat prescribing systems right in each GP surgery is important and the audit set out to look at variations in practice.
The problem was, I made a key mistake from the outset. With no guidelines in place, I invited ten local GP’s to join our audit steering committee to help establish the parameters for the audit and all took up the offer. Three months and several meetings later, we had made little progress. No one could agree the remit of the audit and what the key standards to measure should be and although we ultimately did gain a degree of consensus and 70 local practices participated in the audit, I still look back at that project with disappointment. The good news is that I learned several key lessons, that have helped me ever since. The main one being to keep audit committees and key decision-making groups small! While it might seem a good idea to be inclusive and get lots of stakeholders involved, my advice is to only invite the key decision-makers and experts to the table. In her spare time (!!!) my fellow CASC Director Tracy, serves as a magistrate. It strikes me that there is a very good reason why only three magistrates sit to hear cases and make judgements!
There have been other personal failures along the way, for example, sending out audit forms with mistakes in that the spell and grammar checker did not pick up! Ever since this happened, I now ensure at least two other people quickly review data collection tools I have created to make sure they are fit-for-purpose and contain no obvious errors. When we work on the same project for a long-time, we often become immune from spotting obvious errors and mistakes that others will see in an instant! A fresh pair of eyes is never a bad thing!
To conclude, I urge you to seek to learn from failings but to also share these with others. In clinical audit in particular, people are often keen to publish case studies of their successful audits, but few ever report examples of how they could have done better. And yet this information would be absolutely invaluable, by providing others with a better understanding of where the cliff edge is and thus stopping others from making the exact same mistake and falling off!
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