**5. Using CFC to safety proof health from the sharp end back**

If we accept the model of CFC, it becomes immediately apparent that no amount of activity away from the sharp end of the health-care adverse event will help, least of all the generation of a more policy and procedure. Instead, we need to focus attention on the health-care professional and the immediate socio-cultural environment in which they work [69].

Dealing first with the health-care worker, the selection of these individuals to undertake their chosen vocation is invariably done by consideration of various personal attributes, in the case of medicine academic achievement and individual performance in tests [69–73]. This process and subsequent education takes no account of the fact that as soon as these people graduate, they will be working in a team environment.

The clinical care we deliver (and receive) is a function of the education and capability of our students who will eventually be our doctors and ultimately clinical leaders and decision-makers. What we teach and practise best is the point-of-care medicine and clinical interventions. Therefore, it is no surprise that what we examine and what students focus on are specific point-of-care clinical assessments and interventions [74]. This is best represented by the objective, structured, clinical, examination system (OSCE) that is now a widespread and common form of summative assessment [75]. In the OSCE, candidates undertake clinical assessment tasks at a number of specific stations for 5–8 min. Each station has a structured 'score card' that students must address to get the points. This system of examination in no way gives any indication on a student's ability and competency to comprehensively take a history, perform a physical examination, synthesise these findings into a meaningful problem list and finally and actually least importantly come up with a diagnosis [76]. It has got to the point now in the undergraduate curriculum that the clinical process of whole patient assessment is variably taught and certainly not examined, in a sufficiently stringent manner to motivate students to spend long hours doing patient histories and examinations. Having competent health-care professionals spend time with and understanding our patients is the single biggest step to making health care safe.

Second, priority needs to be given to the core business of hospital care, the interaction at the bedside and clinic between the patient and the various health-care professionals [4, 5, 61]. Clinical futile cycles give a practical platform to understand this culture. We need to accept that an abnormal or an inappropriate workplace culture is at the heart of every major inquiry into poor hospital care [77–82]. Every report into these enquiries recommends change. Yet, 30 years on from Bristol [81], we have mid-Staffordshire [80]. So, what have we really learned from the reports and thousands of pages of recommendations? Nothing. We need a different strategy: one that puts the patient and their well-being first. This should be followed by the implicit understanding that our core business is that of interaction with the patient from the most basic and junior levels. The bedside health-care team needs to be trained, credentialed and supported to deliver better health care, not as individual players, but as members of a team.

#### **6. Conclusion**

the ward. In addition, this grade of doctor is diagnosis–focused and often we see them giving instructions to their juniors (usually appropriately) to organise specialised investigations and other speciality consultations. There is nothing wrong with this, except for the fact that it is

In support of the CFC model is the study that has looked at the causation of adverse events in hospitals [13, 37, 49, 50]. All these studies can assign almost all causation to three human factor issues at the patient interface: competency, cognition (or failure thereof) and culture. Perhaps, the most disturbing example of this was described in the MERIT study, a randomised cluster control study of Medical Emergency Teams (MET) [60] in 23 Australian hospitals (including private and rural hospitals) in 2002. In the nearly 500 cardiac arrests that occurred during the study, in more than a third of instances staff took abnormal (that broached MET activation criteria) patient observations in the 15 min prior to the cardiac arrest, but did not activate an emergency response. The first thing of note with this phenomenon was that the incidence of not calling for help in an abnormal patient situation was high at 30% in the intervention hospitals and 40% in the control hospitals. Put in another way, in the average Australian hospital in 2002, if a patient had documented abnormal signs, in the 15 min before a cardiac arrest, in up to 40% of the time the staff did nothing about this. Another thing of note with these findings is that in intervention hospitals that had an intense education process on the new MET activation policy and procedure, the incidence of calling for help was only 10% greater than the control hospitals [60]. It is here at the bedside with the pre-cardiac arrest patient that the staff are trapped in a CFC, unable to get out of it due to either clinical incompetency (not able to recognise and act for the pre-arrest patient) and/or culture, whereby calling for help maybe

considered not the norm in that ward, on that shift at that time [4, 5, 61–64].

The 'Swiss Cheese' response when RRS fails at the sharp end, for whatever reason, the response is to assume policy and procedure failure, despite the fact that there is no direct evidence for the benefit of Rapid Response Systems (RRS) [62–64]. However, it is well documented that there may be problem with the face validity of RRS due to the very low specificity of the activation criteria [65–67]. Furthermore, there may be problems around staff competency or cultural issues around staff losing face by calling for help. As a result, rather than trying to understand or deal with this very real issue of face validity, possible competency issues and probable cultural issues, the administrative response, all too often, is just to alter the policy

and procedure and make the activation criteria mandatory for the bedside staff [68].

If we accept the model of CFC, it becomes immediately apparent that no amount of activity away from the sharp end of the health-care adverse event will help, least of all the generation of a more policy and procedure. Instead, we need to focus attention on the health-care profes-

Dealing first with the health-care worker, the selection of these individuals to undertake their chosen vocation is invariably done by consideration of various personal attributes, in the case of medicine academic achievement and individual performance in tests [69–73]. This process

**5. Using CFC to safety proof health from the sharp end back**

sional and the immediate socio-cultural environment in which they work [69].

time-consuming [59].

44 Vignettes in Patient Safety - Volume 3

Despite the hundreds of millions of dollars spent on patient safety, we have very little to show for it except the fact that we know that the problem is real, common and universal to all health-care settings. In this chapter, we propose that the reason why we have not been able to improve patient safety is because we really do not understand what is going on at the point of clinical intervention.

The organisational response is based on mandated requirements, which look at system and operational issues. Rarely do we focus on the quality of the judgements made by the individual clinicians involved in adverse events and usually never do we question the clinical culture in which these events occur.

CFC provides an alternative framework to help understand adverse events and patient safety breaches, by forcing us to ask the question, 'they or she/he, knew that there was a problem, or that there might be a problem, why didn't they do something about it?' The question needs to be put to all the involved clinicians regardless of where they sit in the traditional clinical hierarchy. The answer to the question will usually fall into one of three broad categories, first those involved simply did not know what was going on, second, they did know what was going on and they tried to do something about it, and third they did know that there was a problem and for whatever reason did nothing. The answer to this one question then allows for appropriate interventions at the health-care workplace. If the involved individuals were simply oblivious to the situation, then retraining, re-credentialing and recertification are required for those clinicians. If the problem was recognised and attempts made to ameliorate it, then the more traditional root cause analysis should shed light on the issues that need resolution. Lastly, if the problem was recognised and nothing done, then cultural issues are at play. These may range from the obvious (e.g., an overall culture of not calling senior clinicians at night about problems) to more serious issues of workplace bullying and harassment (e.g., senior clinicians when called overnight about problems, being rude, belittling the caller, blaming and side-stepping the problem to avoid coming in after hours).

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CFC also provides us with a term or a condition that describes the 'brain freeze' state of mind that can occur in stressful clinical situations. For the individual clinician, recognising and knowing that they have a moment of 'brain freeze' and that they are stuck in a CFC is the first step to getting out of that situation. The best way out is quite simply to ask for help, or to take time-out to reassess the problem.

In summary, we need to divert some of those hundreds of millions of dollars, away from committees, the quality and safety units, organisational and government mandatory-reporting systems back to understanding the core business of health care, the intervention between clinician and patient. Perhaps, then we will get the significant cultural change that needs to occur (and has occurred in other industries) that puts the saying 'first do no harm' at the centre of all clinical interactions.
