The beautiful thing about patient safety is how it has grown

Maxine Power profile picture

04 May 2021

Maxine Power
Director of Quality, Innovation and Improvement
North West Ambulance Service NHS Trust


The beautiful thing about safety science is its exponential growth in the last two decades. The relentless pursuit of patient safety is every healthcare leader's primary moral obligation. Over my career in the NHS, there has been an introduction of a wealth of safety improvement interventions.

Culture surveys, checklists and structured language (situation-background-assessment-recommendation) are now the norm in much the same way as rapid response teams and incident reporting systems. They are 'things' that we do. Important things. I take nothing away from their importance. Meanwhile an equally important behavioural revolution has been happening in parallel. Behaviours such as problem sensing and its partner sense making.

I am a healthcare leader and my interpretation of problem sensing is the ability of the healthcare workforce to plan for failure and improvise rapidly – always.

Maxine Power    Director of Quality, Innovation and Improvement

Problem sensing has its origins in safety science and has thankfully been brought to the fore by the work of Erik Hollnagel as part of our understanding of Safety II. I am a healthcare leader and my interpretation of problem sensing is the ability of the healthcare workforce to plan for failure and improvise rapidly – always. This helps makes things go right. It's a skill that quite simply reduces harm and saves lives. When you see problem sensing combined with sense making it's a wonderful thing and it is happening in the most surprising places when you stop and pay attention.

We received a 999 call to attend to *David a 55 year old cyclist who, on a sunny afternoon, had collided with a farm tractor on a country road. We mobilised an ambulance, a rapid response vehicle and an air ambulance crew to respond. Five clinicians and one pilot, none of whom had worked together before, to an environment they had never been to before. David was lying in the road with bystanders offering basic first aid when we arrived on scene. The injuries he sustained required treatment at a major trauma centre.

The paramedics worked swiftly to stabilise his injuries, monitor his vital signs, provide pain relief, and give medication to prevent nausea and excessive blood loss. His neck and spine were immobilised, he was transferred to a stretcher, his injured leg was placed in a splint and his pelvis secured. The whole incident was managed in less than 40 minutes. During that time countless tasks were carried out. The crew worked in total harmony, the scene being managed by *John the senior paramedic who knelt at David's head. Like the conductor of the orchestra he deftly coordinated people and tasks. Calmly, John asked David a series of questions, using his responses to guide the team's interventions and sharing information back with David to partner with him in his care.

From my vantage point, the scene looked like a well-choreographed dance, the team working seamlessly together in space and time with a single goal – to prevent deterioration and get David safely to the hospital.

Maxine Power    Director of Quality, Innovation and Improvement

From my vantage point, the scene looked like a well-choreographed dance, the team working seamlessly together in space and time with a single goal – to prevent deterioration and get David safely to the hospital. Under John's leadership the team assumed clear roles, anticipated one another's requirements and communicated continuously with each other. An advanced paramedic, stood back from the scene, managing the environment, the bystanders and shocked tractor driver. Police arrived. The accident scene now blocked to passing traffic.

Built into the cacophony of tasks are risks and complexity. For example we lie patients flat, secured to a stretcher with strapping and blocks at the side of their heads to reduce any lateral motion. This prevents any additional injury but isn't risk free. The nature of the incident, the method of transportation, the medications given or the shock of the incident can result in patients feeling nauseas and subsequently vomiting en route. The life threatening risk of aspiration of vomit into the airway is increased because of the patient's supine posture. This is a situation which any paramedic or air ambulance crew knows well. Anti-sickness medications are given with pain medicines to reduce the likelihood of nausea. Suction equipment is within reach and manoeuvres to safely position patients on their sides are well rehearsed. Throughout the journey reassurances to the patient include prompts to "tell me if you feel nauseous".

I have reflected long and hard about how we articulate what we see, so that problem sensing becomes explicit rather than covert.

Maxine Power    Director of Quality, Innovation and Improvement

The team who attended to David were, in my view, the epitome of a 'problem sensing' team. They characterise today's healthcare professional teams in many ways. Their success is reliant upon so much more than their ability to perform tasks and interventions. I have reflected long and hard about how we articulate what we see, so that problem sensing becomes explicit rather than covert. How many times do we hear "that's just the any we do things around here" in the context of outstanding practice?

On 9 December 1999 nearly 3,000 individuals attended the 11th Annual national forum on quality improvement in health care to listen to an extraordinary address by Dr. Donald M. Berwick, the founder, president, and chief executive of the Institute for Healthcare Improvement. Entitled Escape Fire, Dr. Berwick's seminal speech explored sense making in high reliability organisations, drawing on the theoretical work of Karl E. Weick. He described sense making as having defining characteristics:

  1. Improvisation – the ability to invent when old formulas fail
  2. Virtual role systems – the ability to carry a social system in your head, to assume structures even when they are not externally apparent
  3. The attitude of wisdom – the ability to move forward without excessive confidence or cautiousness in the absence of facts, drawing on synthesis of information available
  4. Respectful Interaction- trust, honesty and self-respect.


I am struck by how, some twenty years later, this speech is as relevant today as it was back then and how these characteristics of organisational sense making apply to our approach to David's care. The team cut away Lycra shorts to assess injury, the stock of blankets on the ambulance was inadequate to provide cover, within seconds a warming blanket from the air ambulance was used to prevent hypothermia. They improvised without fuss. Roles of incident commander, physiological monitoring lead and injury management were silently but confidently assumed. The team were sense making and situationally aware, repeatedly testing and feeding back to one another. Trust was clearly evident, 'check-ins' happened frequently. The short phrase "everyone ok?" punctuated the conversations.

Next time we see healthcare teams in action maybe we should have our problem sensing and sense making glasses firmly in place.

Maxine Power    Director of Quality, Innovation and Improvement

So maybe the answer to the question "how can we become more problem sensing?" has been with us for some time and lies in the art of always demonstrating these four characteristics in our daily work. Surfacing them as behaviours required for safety in today's healthcare and making a shared commitment as leaders to see them, recognise excellence and encourage replication through reward. Next time we see healthcare teams in action maybe we should have our problem sensing and sense making glasses firmly in place.

* Names have been changed for confidentiality.

Maxine Power will be speaking in a breakout session on Can we be more problem sensing? at our Governance and Quality conference this year, taking place on 17-20 May. Book your free member ticket here.

About the author

Maxine Power profile picture

Maxine Power
Director of Quality, Innovation and Improvement

Maxine Power is the director of quality, innovation and improvement at the North West Ambulance Service NHS Trust. She is a Health Foundation and IHI Quality Improvement Fellow alumni.

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