Is tissue harm the mole of patient safety?

Is tissue harm the mole of patient safety?

Safety Culture coach, Ashleigh Phillips neatly summed up the UK’s patient safety challenge in a recently article by saying, “Very few will openly admit that companies today accept a level of risk because the man power and the money it will cost to reduce harm to a lower level doesn’t make good business.” She continues, “I believe that constantly questioning our safety performance and finding areas where we can “break the status quo” is what is required to truly progress the reduction of harm.”

As highlighted by Trevor Dale, “Avoidable harm is not decreasing and the annualised cost increasing in our litigious society. £2 billion outgoings for NHS Resolution in 2018, up from £1.7 billion the previous year.” He also acknowledges that the “Hard thing to do is to get to the true root cause of the issue.” Dr Diane Roberts-Stoler agrees, saying we need to “Treat the cause, not the symptom”.

Protecting patients against tissue harm is one such example where historically symptoms have been treated but the root causes are more challenging to identify and prevent. Like a mole in a garden, tissue damage can be present, but remain undetected beneath the skin, until the symptoms present themselves.

From a medical perspective, any harm that has happened needs to be healed whilst working to the latest legislation and regulations using widely-accepted practices and products. Unfortunately, legislation often lags behind research/ new technology. For example, the REBA scale helps identify the risks of muscular-skeletal injuries to nurses and carers but not how to prevent them. As such, many of the products used for the care of patients confined to bed meet current legislation but not the latest understanding of what happens.

Indeed, there will always be a time-lag between advances in understanding and technology and the wide adoption of them. In 2015, Will Warburton, the Director of Improvement at the Health Foundation highlighted this issue by sharing they were investing “over £7 million into supporting spread at the front line” to help speed up the adoption of new best practices through their Scaling Up and Spreading Improvement programmes. Indeed, it took until December 2018 for new patient safety initiatives are announced which “could be rolled out to all nurses in a bid to reduce cases of avoidable harm and generate a culture change within the NHS”.

Technology is often seen as the solution for improvement and prevention, with the adoption of Artificial Intelligence (AI) is one such an example. However, despite its promises, case studies discussing culpability highlight the consensus that even AI error or harm usually occurs with a series of errors, mostly human in their origin as they too rely on human input originally.

From a legal point of view, “each and every proposal for reform must clearly identify how it improves patient safety and access to justice if it is to genuinely help those working for and relying on our valuable NHS”. If claimant clinical negligence lawyers “welcome well-considered efforts to reduce the incidence and severity of negligence in the NHS”… and the ultimate goal of reforms is to prevent patient harm, the question therefore needs to be asked: When will these new approaches be tried? This is because despite assiduously applying human factors, the incidence of clinical negligence “remains high enough to raise concerns” Commenting on the latest calls for an overhaul of clinical negligence claims, Geoff Simpson-Scott states, “The current FRC proposals must adequately allow for the fact that the underpinning substantive law is not being simplified. However, simplification arising from failures to implement existing human factors lessons intended to improve healthcare is little better. How does this IMPROVE access to justice for either side or patient safety?”

In our view, surely it would be better to avoid the need for patients and their families having to resort to the legal system. In other words, to ultimately improve patient and carer safety, we need to prevent tissue harm. And to prevent tissue harm, we need to understand it.

Like the garden mole we need to know what conditions cause force-related tissue damage, the different levels of invasion and what can stop it. To break the status quo that Ashleigh Phillips mentioned, we need to do something different – as proved by unavoidable harm rates not decreasing. Just as Einstein constantly strived for a deeper knowledge of Physical Reality, so we must pursue advances in our understanding of why tissue harm happens so we can close the gaps in our knowledge to prevent it for patients confined to bed.

We also need to look at what’s really happening in terms of tissue harm and learn from the litigation that’s taking place, which demonstrates that the current ‘prevention’ methods are still not working. Sometimes this is due to a knowledge gap that is an inevitable consequence when trying to disseminate new research and methods across the vast healthcare industry. Behavioural drift and “we’ve always done it this way” mentality also play a part.

The subject of tissue harm is a complex one and whilst present thinking and practices may have the right intentions, they unknowingly resort back to using the wrong solutions when attempting to change the prevention of tissue harm in patients and carers. Joss Colchester describes this conundrum as, “human beings learning to deal with the complexity of the real world”. In other words, we are currently using linear approaches (wrong solutions), to non-linear issues or in Russell Ackoff’s terminology, “doing the wrong things right”.

The good news however, is that research is beginning to identify what’s happening under the surface of the skin. Six states of harm for a cell or tissue have also been identified by Smit: Normal, Adapted, Stressed, Injured, Damaged and Dead. He highlights that even if harm doesn’t necessarily lead to direct damage, even little harm may cause problems over time (a cumulative effect) in the long run.

Smit also emphasises that the body detects and responds to any deviation from homeostasis and will react to regain homeostasis. In his article in Wounds UK, Smit expands this to recommend that understanding of the body’s underlying anatomy and physiology as well as the complex interactions between force, tissue and the body’s natural adaptive system need to be taken into account when planning patient care to avoid force-related tissue damage.

So when caring for patients confined to bed, any movement of them on an interface needs to work with their own internal systems (biotensegrity). By ensuring that the patient’s own weight is initiating the move prevents tissue harm innately. To enable this, the surrounding inbed care environment needs to be managed to promote and support this intuitively whilst also protecting the care-giver from unnecessary risk by preventing manual handling and therefore muscular-skeletal injuries.

Conclusion: by doing what we’ve always done hasn’t decreased the incidences of preventable harm. The healthcare industry therefore needs to break the status quo to understand more deeply the causes of tissue harm so we can prevent them when caring for patients confined to bed.

In the words of British-comedian, Jasper Carrott who had a famous sketch about moles in the 1970s, “It took me just a few days to realise this mole was driving me bonkers… There just doesn’t seem to be any mole catchers left. So it’s a DIY job with moles (Destroy It Yourself).” This is how frustrated I feel about tissue harm and why Phil-e-Slide is committed to its prevention rather than the treatment of its symptoms.


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