DESIGN & CONSTRUCTION
over 140 were seriously injured. It was only after project completion that the true magnitude of harm was realised. A campaign by social reformer, Edwin Chadwick, highlighted that it was safer for an individual to have fought at the battle of Waterloo than to work on the railway tunnel. This shocked the public, and led to a government enquiry and changes within the industry – ‘big data’ being the triggering event. Despite the injuries and deaths being in plain sight to those working on the project, this alone did not generate change.
Figure 2: One of the reasons why the airline industry is so safe is that its safety systems utilise near misses – the base of the Heinrich ratio. These help prevent the serious accidents, and are regarded as free lessons. In contrast, healthcare construction responds mostly to major events. The catastrophe at Grenfell illustrates the Heinrich ratio. The cladding material had been downgraded but was still being used. There had been previous fires but no major deaths. Everyone else was using it, and no one stopped to think what the consequence could be. The minor accidents were not learning points, free lessons preventing a disaster. Perversely, the fact that the incidents had been minor spurred individuals on to carry on using the deadly cladding.
higher than any calculation founded on the mortality of the same class of diseases among patients treated out of hospital would lead us to expect.’ Some 170 years later it is even stranger
that within days of opening new hospitals, such as the The Hôpital Européen Georges-Pompidou in Paris, and the Royal Papworth Hospital in Cambridgeshire, patients are contracting avoidable infections from the built environment, many of which prove fatal. A speaker at the Healthcare Infection Society Spring 2023 meeting detailed how Florence Nightingale’s hospital design provided better ventilation for patient areas than their new hospital, which failed to meet the ventilation requirements necessary to protect patients during the pandemic. While on the one hand Florence Nightingale is rightly revered, with her life being remembered each year, on the other it would appear that most people celebrating fail to understand what she taught us. Mitigating the risks from the built environment should by now have become a highly developed science. Instead, most individuals remain oblivious to the risks. Hospitals may look more advanced, but this belies the fact that they are still harming the sick.
Developing a safety culture – the requirement for a triggering event Florence Nightingale possessed several attributes essential to her success. While everyone else entering a Victorian
30 Health Estate Journal March 2024
hospital could not see the risk from the built environment, she alone not only did, but, being a statistician, was able to provide data to demonstrate the harm. Additionally, she used this to good effect to drive change. Her ability to recognise risk and provide supporting data were key to implementing change – the triggering event. Where such events have occurred in other sectors the nature of the trigger can vary. The Woodhead railway tunnel between Manchester and Sheffield was completed in 1845, having taken six years to construct. Over that period 60 workers died, and
A high-risk occupation This was 178 years ago. Such events surely are relics of the past? Not so. Until relatively recently, working in construction was a high-risk occupation. Deaths and injury were a regular occurrence, although across numerous sites, unlike the tunnel. Even so, they were accepted without question. Analysis of injuries and deaths across industries collected by the Health and Safety Executive identified the construction industry as a major outlier, driving the relatively recent culture change on construction site safety. The trigger for the culture change was ‘large data’.
Healthcare – where a strong
safety culture would be expected to be inherently embedded – is not exempt from such striking incidents. In 2011/2012 neonates in Belfast died from overwhelming infection with an organism known as Pseudomonas aeruginosa. Avoidable neonatal deaths from Pseudomonas were not new. What was different about Belfast was that the number of infant deaths attracted sufficient media attention nationally and internationally to become a triggering event. As a result, HTM 04-01 was published, which – for the first time – recognised the role of water (the built environment) in transmitting
Figure 3: Compliant but not safe – A more mature approach to the way guidance (any guidance, not just the HBN illustrated) is utilised is required to ensure patient safety. The unwritten sentiment within estates and construction is that these documents must be complied with. Some infection control teams quite rightly are wanting to derogate from the HBN, as new information shows safer designs exist. However, project managers and Trust Boards become anxious at derogating. The risk assessment moves from being what is the safest for patients, to will the Board be exposed to criticism/litigation for not blindly following guidance? To date being seen to be compliant with guidance avoids any criticism or legal action, irrespective of whether patients come to harm. Guidance alone does not identify risks to patients.
Used courtesy of the Department of Health
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