Repeating back stops mistakes repeating

On UK railways, a classic example of a high-reliability organisation, several studies have shown that about 70% of all adverse events are caused wholly or in part by miscommunications

Our trio of writers – two doctors and an airline pilot – are co-founders of a business on a mission to improve patient outcomes by helping healthcare professionals understand why errors occur. 

John Reynard, Tim Kane and Peter Stevenson’s third article in their major series hones in on communication failure and outlines simple tools to reduce communication errors in your practice.

Here they focus on just one aspect of the High Reliability Organisation approach to error reduction and the development of a safety culture – the training of front-line staff using story-telling and, in so doing, providing a system for genuine learning from previous mistakes.

‘Research on learning from failures in healthcare is relatively sparse, yet the evidence from other areas of activity – and in particular from industry – reveals a rich seam of valuable knowledge about the nature of failure and of learning, which is as relevant to health care as to any other area of human activity.’ 

The Department of Health report An organisation with a memory, published by the Chief Medical Officer Sir Liam Donaldson in 2000, acknowledged that such an approach had an important role to play in reducing errors, but no systematic approach to this human factors training – training in the psychology of error – has been adopted in healthcare [Department of Health 2000]. 

On the UK railway system, a classic example of a high-reliability organisation (HRO), several studies have shown that about 70% of all adverse events are caused wholly or in part by miscommunications.