The National Patient Safety Agency (NPSA)
has launched a campaign to raise awareness among doctors in training
about what can be done to improve patient safety.
To encourage a more open debate about error, 14 of the nation’s
leading doctors have also contributed highly personal accounts of mistakes
they have made. The document, entitled Medical Error, is available on
saferhealthcare – one stop for knowledge and innovation for safer
healthcare. The Agency is calling on all doctors to report such problems
so that the root causes can be addressed.
Research has consistently shown that doctors are less likely to report
when things go wrong than other staff groups, either because they do
not have time or do not feel they will be treated fairly. For example,
a study on reporting with 65 surgical trainees in Hull and East Yorkshire
Trust found that only 33% had ever reported an incident. The most common
reason given for not reporting was that it was not in the doctors’ culture.
Of those surveyed, 42% said they would report more if the system was
anonymous.
The NPSA has worked with the Medical Defence Union and Medical Protection
Society to publish a new handbook for junior doctors which provides them
with practical advice on how to reduce risk, and highlights the importance
of reporting and the need to change systems to protect doctors from error.
The publication is supported by the British Medical Association’s
Junior Doctors’ Committee. A complimentary copy will be sent to
43,454 of BMA’s junior members.
The vast majority of NHS care is safe and effective with over a million
patients successfully treated every day. However errors do occur and
the NPSA collects reports from healthcare staff and patients, to identify
recurrent patient safety problems and develop national solutions. If
doctors report locally, the NPSA will automatically receive this information,
however, they now also have the option of reporting anonymously online
direct to the NPSA at http://www.npsa.nhs.uk/staffreports
NPSA Medical Director Professor Sir John Lilleyman said:
“ We know
there are various reasons why doctors might not report an incident, including
lack of confidence that they will be dealt with fairly. Yet the very
best doctors can make mistakes, and these mistakes often stay with them
throughout their working lives.
_ We want
to help protect doctors from error by changing the systems they are working
in so that it is much harder, for example, for them
to mix up two very similar drugs or confuse two patients with the same
name whilst under pressure. We want more doctors to report locally or
nationally to enable us to learn from what goes wrong and put the right
safeguards in place. We understand that until doctors feel they are working
in a more open culture, we will need to have an anonymous reporting system.”
Mr Simon Eccles, chairman of the BMA's Junior Doctors Committee, said:
" Doctors,
in common with all other professions, make mistakes. Until now the prevailing
culture in medicine has limited how much we have learned from other doctors'
errors. This NPSA publication must help to foster a more open attitude.
The best way to avoid repeating a mistake is to know about it and learn
from that knowledge."
The NPSA has focused on a number of changes to the systems in which
doctors work to improve patient safety, including:
- Standardising the hospital crash call number used to summon the resuscitation
team. The NPSA found that 27 different numbers were in place which
is confusing for staff on rotation and can cause delay.
- Improving the storage of potassium chloride concentrate, which if
administered by accident can be fatal.
- The cleanyourhands campaign that puts alcohol rub by the bed so
that busy staff can clean their hands easily and reduce the spread
of
hospital infection.
A new training programme for junior doctors
was also recently launched by the Chief Medical Officer for England
Sir Liam Donaldson. This
programme puts patient safety at the heart of the medical curriculum. Dr Gerard Panting, Communications and Policy Director of the Medical
Protection Society said:
“ All doctors make mistakes, sometimes
with tragic consequences for patients, their families and those healthcare
professionals involved. Whilst eradicating medical errors is an unachievable
goal, there is scope for reducing the frequency of things going wrong
clearly to everyone’s benefit. This initiative aims to do just
that and richly deserves the support it has received from all quarters
of the medical profession.”
Dr Stephen Green, head of risk management at the Medical Defence Union
(MDU), said:
" Our members often tell us of the terrible distress
they feel when they make a mistake and the case histories in this report
illustrate this only too well. Doctors are often surprised to learn that
a significant proportion of incidents reported to the MDU can be traced
back to lack of procedures or systems failing, rather than to lack of
individual clinicians' knowledge. It is vital that we learn from incidents
and near misses. By reporting them we can identify the changes that need
to be made to help prevent history repeating itself and to try to ensure
that patients don't suffer unnecessarily."
More than a million people are treated successfully every day in the
NHS. However, medical advances have lead to an increasingly complex system
in which things will and do go wrong, no matter how professional and
dedicated the staff. There were 85,342 incident reports to the National
Reporting and Learning System (NRLS) between November 2003 and 31 March
2005 affecting 86,142 patients. 68% of incidents resulted
in no harm to patients. Approx 1% of incidents led to severe
harm or death.
News is included on this website
to inform visitors about current health issues, but not to endorse
any particular view or activity. Material in this news item
was first released by the National Patient Safety Agency (part
of the UK NHS), UK on 8th September 2005. For further information, please
visit
their
website using the link below.
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