James Reason on medical error

[Genghis the Engineer]

(I'll bollock myself later for a double post, as I also posted this on the CRM forum).

I just heard the trailer for this...

BBC - BBC Radio 4 Programmes - Doctor - Tell Me the Truth (http://www.bbc.co.uk/programmes/b01cc1q4)

Should be half an hour worth listening to I'd think. Hopefully will be available on iPlayer for a while afterwards for those with something else planned for a Monday night!

(James Reason, for those who don't know, is the originator of the "swiss cheese" model bedded into most CRM training now.)

G

[gingernut]

Haven't heard the show yet, but expect they're tlking about "Significant Event Analysis."

It's something positive that we picked up from the aviation industry. In our surgery, we partake in the process weekly, and it's infinately better than what we used to do - (standing at the bar saying "phew, had a close one today.")

Of course, building stuff into the system to stop us mere humans making mistakes in the first place, also helps.

http://img.photobucket.com/albums/v617/gingernut123/fuelcap.jpg

[Genghis the Engineer]

I got the impression from the trailer that he was most likely going to be talking about open no-blame reporting of failures.

His book "The human contribution" has some fascinating stuff about medical errors and how they can be prevented. A lot seemed to concentrate upon the willingness to identify, rectify, and report mistakes.

Building stuff into the system to prevent error is more Atul Gawande's territory to some extent.

G

[homonculus]

Sadly there is no such thing in the uk

Two years ago the chief medical officer launched an on line reporting system for anything from concerns through near misses to deaths

But it isn't in any way confidential so you have to be a bit silly to use it. Bullying is rife in hospitals and sadly some managers would use a report against the author. As for the lawyers......

Medicine always thinks it is safe and state of the art but in terms of crm and reporting and modifying practice we remain in the dark ages

[Genghis the Engineer]

I suspect that may well be Professor Reason's point - but I plan on listening to the programmes to find out.

G

[Genghis the Engineer]

Postscript, having listened to episode 1 - it would appear that Prof. Reason agrees with you completely Homonculous.

G

[gingernut]

Bullying is rife in hospitals and sadly some managers would use a report against the author. As for the lawyers......

Medicine always thinks it is safe and state of the art but in terms of crm and reporting and modifying practice we remain in the dark ages


Yes, perhaps I'm being to optimistic.

Significant event analysis was meant to be for "the greater good."

Unfortunately, it is used more of a threat..."I'm thinking of raising a SEA about this.."

[Loose rivets]

I recall a pal telling me about a surgeon that took out ever increasing lumps of his patients, most of them dying as a result. No one dared challenge Sir whaterverhisnamewas. Until finally, a chap with balls stood up and said the Emperor has no clothes. He was senile, but waaaaaaaaay too important to be criticized.

[Mac the Knife]

That was Ernst Ferdinand Sauerbruch (3 July 1875 – 2 July 1951) in Germany.

A great surgical pioneer and Nazi opposer who developed Altzheimers.

Hardly relevant to today....

:ok:

[homonculus]

Sadly I came across similar when training but it is very unlikely nowadays due to appraisal

Those who recall the Bristol babies scandal may be interested to know the brave anaesthetist who blew the whistle was hounded out of the UK

[gingernut]

I was hoping things had moved on a bit since the Bristol case, and I, for one, was a great advocate for audit, significant event anlaysis etc etc, and I was, at one time, greatly enthused by the likes of people like Aiden Halligan, who told me that he had learnt an awful lot around safety, from the aviation world.

It does mostly rely on self reporting, and I'd have to agree, we've never really got to the point of a "no blame culture," some of us were hoping for. (Although, things are gradully improving.)