A tale of two SIRIs – Adrian Plunkett

Our attempts to improve patient safety in the NHS have tended to focus on learning from error.  Intuitively, this seems like a good idea:  if we make a mistake, we would like to learn why it happened and how to stop it happening again.  But errors only occur in a minority of clinical encounters, so our focus is quite narrow.  We may be missing learning opportunities from the episodes when things have gone very well.  When excellence happens in healthcare, we have a tendency to simply accept it gratefully and move on.  Imagine if we could capture those episodes in order to understand how to repeat them.  We might not only gain useful insights to improve quality of care, but we might also improve staff morale through appreciation and recognition.  

This is the theory behind Learning from Excellence – a system for reporting and studying excellence in healthcare. Our philosophy and a blog with resources is available on our website:  We have been capturing and studying excellence for over a year now, and we encourage all healthcare professionals to do the same.  

The fable below describes how a fictional NHS department discovered this approach to safety investigations.
– Adrian Plunkett., consultant in Paediatric Intensive Care Medicine at Birmingham Children’s Hospital

A tale of two SIRIs*

“Welcome everyone. Thank you for coming to this SIRI meeting. Before we start, shall we just do a quick round of introductions?”  Julia hoped her cynicism didn’t come across when she spoke. Having chaired many similar meetings previously, she was starting to doubt whether this process was effective.  The purpose of the meeting was to investigate an episode of medical error, to understand why it happened, and to make recommendations to stop it happening again. Julia had many years of clinical experience as a consultant anaesthetist, and had a genuine interest in improving patient safety. So why was she starting to doubt the process?  The truth was that she had seen the negative effect on her colleagues. She had noticed that colleagues under investigation are almost always fearful. She saw them lose enthusiasm, become jaded, and start to become defensive in their work.  She had also noticed that many of the recommendations from previous SIRIs were either not implemented, or were simply not effective; as certain incidents seemed to keep occurring.

She did her best to smile and make eye contact with each member of the panel as they introduced themselves.  Let’s keep this positive, and get it over with, she thought.  James, the commissioner, started the introductions. He was the only member who Julia hadn’t met before.  It is a requirement of the SIRI process that a commissioner attends the meeting, but Julia found it uncomfortable discussing mistakes of the hospital in front of an external member.  It felt like owning up to misbehaviour in front of the teacher at school.  Thankfully, James spoke with a positive and empathetic tone during his introduction. Julia made a note to herself to tap his positivity if the meeting got a little too depressing.

Sandra and Gavin went next, in quick succession.  Both were consultant colleagues of Tim, who had made the error which sparked the SIRI.  Gavin had actually discovered the error and filed the original incident report.  When reviewing all the statements for this meeting, Julia couldn’t help thinking that Gavin had been a little too efficient with the timing of his incident report.  It might have been more helpful to let Tim report the incident himself.  Gavin’s accompanying statement was also a little condescending to Julia’s taste, and it included several references to his own practise which didn’t seem to serve any purpose other than to highlight his superiority.  Sandra’s statement, on the other hand, was brief and unhelpful, and looked like it had been written with minimal effort.  Julia had worked with Sandra for many years and was well aware of Sandra’s disdain for the patient safety investigation process. “The whole process is painful and pointless”, Sandra had declared at a recent governance meeting. “Mistakes happen. We all drop the ball sometimes. We just need to be more careful, and get on with our jobs.” Sandra had made many such proclamations in the past and had a habit of rolling her eyes whenever patient safety was discussed in departmental meetings.

Tim introduced himself next. “I’m Tim”. He hesitated, then continued, “I’m the reason you’re all here. I made the mistake, and … and, look… I’m sure it won’t happen again.”  Tim was in his second year as a consultant anaesthetist. Julia thought he looked smaller than usual, as if the whole process was reducing him somehow. She remembered his statement had been brief but thoughtful, and tinged with regret. She had no doubt that he had indeed learned from his mistake.

“I’m sure that’s true, Tim,” said Sandra. “Let’s try to remember that this is not about apportioning blame. We are here today to try to understand why this happened, and to identify the root cause of the error, so we can prevent it happening again”. As she spoke, she noticed James nodding in agreement.  Gavin was smiling and Tim just looked at his papers on the desk. No one looked at Sandra, but everyone knew she was rolling her eyes.

And so the investigation started. Julia talked through the terms of reference for the investigation, as she had done many times before. Then the event itself was discussed repeatedly in exquisite detail. All the ‘evidence’ came from the recollection of the staff members who were directly involved in the event. Julia reflected that it was impossible to understand fully the context of the episode: was Tim tired that day; did he have a lot on his mind; were there a lot of distractions in theatre? None of this information was available. The incident itself was a simple drug error: Tim had given a drug to which the patient was known to have a severe allergy. The patient had become profoundly unwell and required rapid intervention. While Tim was responding to the deterioration, Gavin had come in and ‘saved the day’, at least that’s what Gavin’s statement had implied. Reading between the lines it appeared that Tim had already picked up on the deterioration and was putting things right.

Nevertheless, a mistake had happened, and the patient had required a brief stay in intensive care, which would probably not have been required if the drug error hadn’t occurred.  During the meeting, which lasted for nearly two hours, Tim hardly spoke, other than to express regret and how he has learnt his lesson. By the end of the meeting, the panel had agreed that the root cause of the error was a failure of the whole team to carry out the patient safety checklist correctly – they had all missed the allergy when ticking the checklist items at the start of the case. Julia knew that this was an oversimplification, but it was the best that they could do. The meeting finished with agreement over the recommendations to changes of practice to prevent a recurrence. These recommendations were simply a re-emphasis of existing guidelines and good practice.

After the meeting, Julia stayed behind and drafted an outline of the report while she ate a stale sandwich.  There was no time for a more substantial lunch as she wanted to get the main points down before running to her afternoon theatre session on the plastic surgery list.  It wasn’t her favourite list, and to make matters worse, on this particular day, the surgeon was very slow, and the whole session ended later than planned. As she took the last patient into recovery, Julia noticed a red band around the patient’s wrist signifying severe allergy.  She couldn’t remember if she had been aware of the allergy, despite the fact that this had been an item on the safety checklist.  She found herself thinking about Tim, and how easy it can be to make a drug error.  There but for the grace of God go I, she thought.

Julia mulled over the events of the day as she walked to the staff car park that evening. She was deep in her thoughts as she walked to her car. As she reached for her car door, she noticed she had parked next to Tim. She saw him sitting in the driver’s seat, deep in his own thoughts. She knocked gently on his window and waved.  He looked up, slightly embarrassed to be caught day dreaming, and let the window down. “Hi Julia. Thanks for being sympathetic today in the SIRI meeting”.  Tim looked sad and washed out. His spark had gone.

“It was a good meeting. I think we’ve come up with some good recommendations,” she said, sounding a little unsure of herself.

“Yes, yes. I’m sure you’re right,” said Tim. “The thing is I’m still not sure the same error won’t happen again to someone else. I keep thinking about that day and I think the problem is deeper than you think. There’s a whole negative culture around the safety checklist. It’s like no one really ‘gets it’ in that theatre.”

Julia wondered why Tim hadn’t mentioned this in the SIRI meeting.  She realised that she could have supported Tim more during it.  “Well, we did seem to agree that the root cause of the error was due to the failure of the checklist to highlight the allergy,” she said.

“Yes, but I think it’s deeper than that. The root cause analysis is a bit simplistic, don’t you think?” Tim looked frustrated, slightly angry. “The world is more complex than that. There isn’t a single root cause for every event. It’s just not that simple.”

Julia nodded. She agreed but didn’t know what else to suggest. “Maybe you’re right, Tim. But what else can we do to try to understand medical error?”

“I don’t know,” said Tim as he put his key in the ignition. “But it’s weird how we can get it so right sometimes, and so wrong on other times. Maybe we should start looking at the times it goes really well, and try to learn from those episodes.” Tim paused before he prepared to drive off. “I mean, have you seen what they do in Mr Thom’s theatre for the checklist? It’s amazing. I anaesthetise for him sometimes, and I’ve seen what they do. They’ve got the checklist down to a tee.”

“No, I’ve not been in that theatre. I’ll check it out. Thanks Tim.”

As Julia drove home she found that she couldn’t stop thinking about Tim’s idea. Why don’t we investigate the episodes which go really well? The more she thought about it, the more she realised that episodes of excellent practice are likely to have important learning points too. And investigating episodes on the ‘excellent’ side of the quality spectrum would be a considerably more positive experience than chairing a SIRI meeting. Julia felt a rising sense of optimism and enthusiasm as she thought more about this concept. By the time she got home she had made a pledge to herself to organise a ‘reverse SIRI’: an investigation into an episode of excellence. And she knew just the place to start…

“Welcome everyone. Thank you for coming to this reverse SIRI meeting. Before we start, shall we just do a quick round of introductions?” Julia looked at the panel for this first reverse SIRI meeting. When she first pitched the idea of this meeting at a recent governance meeting, she had expected a lack of engagement for her cynical colleagues.  Now, as she looked around the table, she was pleasantly surprised at the response to the invitation. She had asked Tim to ‘report’ the excellent practice in Mr Thom’s theatre, and she had invited some of the theatre staff to attend the meeting, along with Tim and Sandra from the previous investigation. This time, Tim started the introductions. Julia had been worried about Tim since the last SIRI. Like many colleagues before him, he was taking a long time to bounce back from his medical error. He had often appeared nervous or angry at work over the last few weeks. Today, however, it looked like he had regained some of his spark.

As he introduced himself and explained that he had come up with the idea for investigating excellence, he seemed genuinely upbeat.  James the commissioner still came across as sensitive and positive, although he did have a slightly bemused look on his face. Sandra went next. Julia hadn’t been sure that inviting Sandra would be wise, given her obvious disdain for the patient safety movement. Indeed, Sandra did appear to be somewhat disinterested and had checked her phone twice in the first 5 minutes if the meeting. At least she’s not rolling her eyes, thought Julia. The last two introductions were from members of the theatre team under investigation: a theatre nurse called Satnam who beamed from ear to ear throughout the whole meeting, and Robbie, an Operating Department Practitioner (ODP) who made a point of thanking Julia for the ‘appreciation’ of the work they do in Mr Thom’s theatre. Mr Thom himself wasn’t available, as he was giving a lecture on quality improvement at a major conference overseas.

“OK thanks,” said Julia. “You’re probably wondering how this meeting will work, as we haven’t done this sort of thing before. Well, the truth is that I don’t really know myself. It’s an experiment really, so bear with me. I’ve done some serious thinking over the last few weeks and I’ve come to the conclusion that we are missing learning opportunities from excellent practice. We have tended to focus all our safety and quality improvement work on identifying and eliminating error. That’s fine to a point, but by only looking at error, I think we have ended up creating a culture of negativity. So when Tim told me about the way that the safety checklist is carried out in Mr Thom’s theatre, I thought we should try to figure out what is going on there. Maybe it would be possible to replicate it in some of the other theatres.”

“Isn’t this just ‘sharing best practice’?” said Sandra.

“Well, yes. I suppose it is,” said Julia. “But that’s not something that happens much around here. Can you remember the last time we did it?”

Sandra just shrugged, confirming Julia’s suspicion that sharing best practice doesn’t really happen. It’s like we all work in our own silos, she thought.

Julia carried on. “I initially thought we could try a root cause analysis approach to investigate this, but on reflection, I don’t think that methodology is adequate for our requirements. In fact I’m not sure it’s adequate for our purposes in any safety investigation, but that’s another story. So I’ve done some reading and I came across a methodology called ‘appreciative inquiry’, or ‘AI’. I want to give it a go, so bear with me while we try it out.”

“Sounds very funky,” said Sandra in the most cynical tone in her repertoire.

Julia just smiled at her. Sandra rolled her eyes.

The meeting then started with a description of what actually happens in Mr Thom’s theatre during the checklist. Julia asked Tim, Satnam and Robbie to describe the whole process in as much detail as possible. Julia only spoke to seek clarification or to prompt for more detail. As the story unfolded, Julia became more and more certain that she was doing a good thing. The panel heard about proper teamwork. Each member of the theatre team, including Mr Thom, participated in the checklist; they took it in turns to lead the checklist, and everyone knew when it was their turn as the rota was written on the theatre wall. There was apparently no hierarchy to speak of, and there was clearly a sense of cross-disciplinary respect. All theatre team members were on first name terms. Mr Thom was called Ulrich, apparently, which was news to Julia. The panel learned that the theatre was silent during the checklists, except for the team members who were talking. Everyone gave it their full attention. The story went on and on, with a detailed description of a beautifully engaged team who prioritise safety. Tim, Satnam and Robbie each gave several anecdotes to add weight to the whole story. Julia’s favourite part was when Robbie explained that there is a prize for anyone who manages to find an error or problem which needs to be addressed – Robbie won the prize one day when he highlighted a patient’s allergy to an antibiotic which would normally have been used in the surgical case. Julia was fascinated to hear that the ‘prize’ itself wasn’t anything material, but it was simply a note of commendation and ‘appreciation’ written by Mr Thom and emailed directly to Robbie. Robbie described how he had used this as evidence in his recent appraisal.

As she looked around the room, Julia noticed that everyone in the meeting was engaged, and Sandra had not checked her phone for at least 10 minutes. She even noticed her taking some notes at one point.

As the meeting progressed, Julia steered the panel through some other questions. She asked then how they felt when they were working in this environment. “How does this line of enquiry help us?” asked Sandra. Before Julia could answer, Satnam said, “It motivates me to do a good job. I feel like I’m valued and part of a team. It feels safe – for the patient and the staff.”  Sandra raised an eyebrow, then smiled and said “It feels safe? OK. I get that. Very interesting.” She had lost her cynical tone.

Taking advantage of the momentum, Julia introduced the next topic for discussion, by asking the panel to think about how to recreate this excellence in other theatres. After a short pause it was Sandra who spoke first. “Well, it seems to me that you’ve got a really good thing going. I’d like to come and see it myself. Do you think I could come and observe?”

Satnam nodded.  “Yes, of course. Good idea. We could easily accommodate some observers if anyone would like to come and see for themselves.”

“Like a showcase,” said James.

“Yes, this is good,” said Julia. “We could try to role-model this excellence.”

“Perhaps we could write this up in some sort of report. And share it with everyone in the department. Like an excellence bulletin?” offered James.

That’s not a bad idea, thought Julia. “By highlighting excellence in the department, others might be able to emulate it?”

“Worth a try,” said James.

“Indeed it is,” said Julia. She looked up from her notes and saw that everyone was smiling and nodding. What a difference from the usual SIRI investigation, she thought.

The panel discussed other ideas to improve checklist behaviour, based on Mr Thom’s theatre’s practice. Some ideas were good, and some were less good, but after a short while they had produced a list of ‘recommendations’ and they had agreed to share these as learning points and suggestions for other theatres to adopt or learn from. Julia tasked herself with drafting the report.

Just as Julia was about to call the meeting to a close, Tim spoke. “Julia, thanks for arranging this meeting. It’s been really great, and I think we should do more of it. It’s clear to me that we can learn from excellence if we can develop a method to capture it. So how about a simple reporting system? To complement our adverse event reports, why don’t we introduce system for reporting excellence? Just a simple online form to capture some basic information; we could use it whenever we notice something excellent. It could be a great way to identify areas of good practice which warrant further investigation.”

Sandra looked impressed. “Now that is a safety process I could really get on board with. It could be the antidote to adverse incident reporting.” she said. “Shall we call it ‘Learning from Excellence?'”.

Everyone agreed and Julia closed the meeting.

About the author

Adrian Plunkett is a consultant in Paediatric Intensive Care Medicine at Birmingham Children’s Hospital.  He has several clinical and non-clinical interests, but a common theme in all his work is a desire to discover new solutions to existing problems. 

* SIRI stands for Serious Incidents Requiring Investigation