The focus of CORESS is on detecting and learning from no-harm, near-miss and low harm events encountered during routine surgical practice. The programme collects reports of such events, analyses them and disseminates the learning contained within them to a wide surgical audience and other agencies involved in Patient Safety matters. These events are known collectively as ‘Accident Precursor Events’ or simply ‘Precursors’. CORESS does not have sole rights over discovering or acting upon Precursors: there are many agencies focussing on various aspects in this area.
The CORESS Approach to Supporting Patient Safety
What CORESS does, which is different to others, can be summed up as:
- Discovering Precursor Events that go otherwise undetected or unrecognised
- Raising awareness among the staff who are best placed to recognise and detect them
- Disseminating the lessons learned to the most relevant cohort of professionals, in a succinct, timely and accessible manner
‘Sinister Harbingers of Disasters’: the Significance of Precursor Events
In 1931 Herbert Heinrich, an insurance assessor concerned with reducing the incidence of industrial accidents, first drew attention to the relationship between precursor events and major accidents. He portrayed this as a pyramid. Later, Frank Bird went further and postulated an escalator of near-miss, low harm and unnoticed episodes and theorised a ratio of 600 precursor events to a major accident. Others have attempted the same exercise in manufacturing industry and whilst there have been criticisms of the ratios postulated, it is generally accepted that the relationship not only exists but is very strong.
Why is it important to detect Precursor Events in medical practice?
It is evident that if precursor events can be detected and timely action taken, more serious consequences can be prevented. Since Heinrich introduced the concept, many authorities have drawn attention to its importance – particularly in high stakes industries such as aviation, transport and nuclear. Witness the loss of the spacecraft Challenger due to an ‘O’ ring failure where the significance of multiple minor failures of this component in previous launches had gone unrecognised. Several instances of foreign runway objects causing damage to Concorde had been recorded prior to its total loss in July 2000. Yet in medical practice it is only in relatively recent years that the significance of precursors has been recognised and system changes introduced in, for example, specialties such as surgery and anaesthesia.
Is it easy to detect Precursor Events?
Theoretically, yes, but in practice much less so. There are multiple factors in play.
Examples of Precursor Events would include a wrong dose drawn up and administered but with no adverse consequences; or the mislabelling of the side or type of operation on an operating list but detected just in time. Often the only person in a position to recognise a low harm event is the person involved; if that person fails to appreciate its significance and report, the opportunity for pre-emptive action is lost. Factors mitigating against detecting and reporting precursor events include:
- Fear of retribution or personal consequences
- Failure to recognise a situation or event as a ‘Precursor’
- Lethargy and/or time constraints
- Bureaucracy
- Poor ‘Safety Culture’ in the workplace
An enquiry by the Kings Fund in 2016 described one of the problems well:
“People spoke of feeling embattled and isolated, working ‘in the implementation gap’ – and of the personal sense of shame when things go wrong. This in turn leads to self-silencing and a consequent lack of open conversation that could help to identify and tackle problems in the wider system. If one assumes that most care is characterised by complexity, then just focusing on individual behaviour is simplistic, unethical and part of the reason why there is an implementation gap in the first place.”
How does the CORESS address the ‘nervousness’ of reporting: The ‘Honest Broker’ approach?
Learning from Aviation that one of the most important barriers to reporting is fear of personal consequences – real or perceived – CORESS is designed as:
- An independent charity
- A confidential service
- A secure service
‘It was discovered some years ago, that professionals, even operating in a developed safety-confidential environment such as aviation, reported more readily and to a far greater degree to a third party that was clearly separate from employers or regulators.’
To achieve this CORESS has adapted the successful Confidential Human Factors Incident Reporting Programme (CHIRP): https://www.chirp.co.uk
How does CORESS use reports of Precursor Events?
After analysis and a process of editing, which disidentifies the origins of the report, the learning is disseminated in the form of regular feedback published in a number of widely read surgical journals. Narrative style is recognised as an effective method of engaging the reader’s attention and for this reason ‘CORESS Feedback’ takes the form of a series of stories or ‘vignettes’; often written in the first person.
The reports are also lodged on the CORESS website and freely available to the public. CORESS uses its established links with regulators to forward specific safety issues identified by its Advisory Committee.
Why should a member of a surgical team report a near-miss, low- or no-harm event to CORESS rather than, or as well as, workplace reporting systems
Hospitals are obliged to have in place several systems for capturing Patient Safety issues. The issues concerned range from so-called ‘Never Events’, which are highly visible and require mandatory central reporting and investigation, through to concerns raised by staff and aired at regular Governance’ meetings.
Important for local recording and discussion as they undoubtedly are, significant learning opportunities discovered at the workface frequently deserve much wider attention, but rarely progresses beyond local level – thus failing to reach the professionals best placed to take effective action on behalf of the patients they serve.
A recent impact study demonstrated that CORESS has already established a substantial specialist audience which, given the resources, it will be able to expand.