Ep 10 - The HSSIB with CEO Dr. Rosie Benneyworth

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Show notes

• The Health Services Safety Investigations Body (HSSIB) investigates patient safety concerns in the UK. They are an independent body with the aim of making healthcare safer.
• Excellent care is one goal, but well-connected and easy to navigate care is an entirely different matter.
• In the current healthcare system, it is practitioners that are keeping people safe by filling in the cracks in the system, rather than the system helping to make it easy for practitioners to get it right, and harder for them to get it wrong.
• Dr. Benneyworth on behalf of the HSSIB notes the importance of meeting people who have been harmed by the system. Listening to patients is important, including if not especially after a bad outcome.
• The Stafford Hospital deaths was an inciting event for the creation of the HSSIB.
• A significant benefit of the HSSIB is that it has healthcare, human factors, and other industry expertise that is ready to investigate immediately, rather than waiting for a commission of inquiry to be stood up.
• Canada does not have a national healthcare system. What started as a social experiment in Saskatchewan with Tommy Douglas, became what we now know as the Canadian healthcare system because of a cost-sharing legislation (The Canada Health Act).
• As healthcare is mostly administered under the provinces, there is nothing stopping a province from creating a body like the HSSIB.
• Despite the HSSIB being a relatively new body, there is already evidence of its efficacy. For example, after the aortic dissection report, evidence suggests that approximately 300 more people a year are being identified as having an aortic dissection and are getting life-saving surgery.
• Just as some issues require a national response, there are likely issues that require a multinational response (e.g. medical devices, similar to how airplanes are subject to Airworthiness Directives / grounded for mandatory maintenance).
• The National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD) is an audit-based body that also helps improve patient safety.
• The HSSIB does a lot of work in observing how work is actually performed in healthcare (work as done, as opposed to work as imagined).
• Providing empathetic care can protect against burnout.
• As the HSSIB retained sponges report shows, by redesigning the system (e.g. RFID tagged sponges) we can improve patient safety, increase efficiency, and reduce costs all at the same time. Improved safety does not necessarily mean increased costs, in fact, in the HSSIB’s experience, the opposite is true - that the safest organizations are often the most efficient.
• OR / Resuscitation Recorders
  • In the sponges report, the HSSIB was not able to determine what happened in the reference event where sponges were left inside a patient. This is because the only evidence available was from the people’s memories of those events.
  • The HSSIB did not turn their mind to recommending OR recorders.
  • In aviation, the black boxes (Cockpit Voice Recorder and Flight Data Recorder) were invested to gather such evidence.
  • Concerns raised regarding the potential use of OR recorders
    1. Medical culture (are we ready for them?);
    2. Patient privacy;
    3. Misuse of the data (i.e. for discipline); and
    4. Cost of installation and maintenance.
  • Adam’s rebuttal of these:
    1. Medical culture is informed by the use of technology and as the HSSIB gains a reputation for safety, a just culture emerges. Rather than wait for medical culture to change, we can change medical culture through the appropriate use of this technology (just as we did in aviation).
    2. Patient privacy: gain consent (as is currently done by the few organizations that currently use OR recorders) or anonymize.
    3. Misuse of the data (i.e. for discipline) - legislation and policies similar to what currently exists in aviation. Also, only the safety investigator and no one else can access the data; and
    4. Cost of installation and maintenance: in terms of cost-benefit analysis, this is a low-cost for significant benefit.

Safety Intervention Worth Mentioning: Health Services Safety Investigations Body (HSSIB) reports

1. The Health Services Safety Investigations Body (HSSIB) (where you can subscribe to their mailing list)
2. HSSIB Report: Retained swabs after invasive procedures (April 16, 2024)
3. HSIB Report: Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia (April 19, 2021)

Other resources

1. The Stafford Hospital deaths was an inciting event for the creation of the HSSIB.
2. The National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD) is an audit-based body that also helps improve patient safety.

Random recommendations

1. Rosie: Disney+ Suspect: The Shooting of Jean Charles De Menezes
2. Adam: Be inspired by the expertise and passion people have in a field other than your own. I was reminded of this by famed US author, lawyer, and happiness guru Gretchen Rubin. She recently told the story of a colleague of hers and linked to a CSPAN panel that she was on about former US Supreme Court clerks.
3. Amir: Awakening from the Meaning Crisis by John Vervaeke (50-part lecture series, YouTube, free)

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