Patient Safety Education in the UK

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In 2001, Wayne Jowett died after having the wrong drug – vincristine  – injected into his spine. He was not the first to die from this, nor the last.

Wayne Jowett, Died in 2001 due to medical error
Wayne Jowett:(© BBC news)

The Harvard Study in the USA discovered that 1 in 200 hospital admissions led to death due to an adverse event, of which two thirds were due to error.

To date, much empahsis has been placed on re-engineering health-care systems to transform them into so-called high reliability organisations along the lines of the airline, nuclear and oil-rig industries where risk is carefully managed to prevent harm.

However, it’s unthinkable that this situation can be improved by changing the workplace but not the workers. In order to deliver safe health care, clinicians require training in the discipline of patient safety. This was recognised in the recent Parliamentary Health Select Committee report, where the acquisition of non-technical skills (including teamwork, communication, situational awareness, Human Factors) was noted to be lacking in the UK.
There are a number of Patient Safety education frameworks in existence now, including in Australia, Canada and the USA. The World Health Organization Patient Safety Programme has now launched a Patient Safety Curriculum Guide for medical schools (and is developing a multiprofessional guide) representing international consensus on curriculum content.
The General Medical Council has mandated Patient Safety knowledge and skills in Good Medical Practice and Tomorrow’s Doctors 2009 (in consultation), and the importance of Patient Safety has been endorsed at UK governmental level and European level  as well.
Medical students internationally have recognized the need for Patient Safety education. The University of Aberdeen is leading the way in Scotland and is now implementing the WHO Curriculum. Isn’t it time that medical schools in London led the way for England too?
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5 Responses to “Patient Safety Education in the UK”

  1. anthonypho Says:

    Excellent topic for post. As an RN at JHH, I’ve found generally speaking that the staff follow the “culture of safety” as prescribed by the IOM; mistakes should no be treated punitively but rather focusing on system flaws as the blog points out. In fact Peter Pronovost (JHH MD, PhD) was recently awarded the McArthur award for his work on safety. His original study in catheter insertion infection in the NEJM illustrated the power of safety checklists:
    http://content.nejm.org/cgi/content/full/355/26/2725

    That said, the poster points out that teamwork and communication are noted to be lacking in the UK. I truly believe this to be the larger issue. It’s not just about education doctors but rather the entire multidisciplinary health care team including nurses and pharmacists and others. I’ve observed first-hand when nurses don’t ask a question for fear of reprisal from a doctor and when doctor’s don’t question nurses for similar reasons. There’s a lot of ego and pride involved in the medical environment and much of the culture we work in perpetuates this behavior at the cost of patient safety.

  2. kwcheung Says:

    I agree with the above comment. A very timely post on a very important topic.

    As a physician in Canada, the topic of clinical adverse effects has definitely centred around systems problems, and I think rightly so. The culture of blaming individuals for medical errors has shifted towards identifying systems solutions to reducing errors. For example, medical errors may involve physicians, nurses, pharmacy, labs, etc, and all parties are essential in identifying potential medical errors. Medical professionals work as a team and individuals are all accountable to each other.

    Although not complete or universal, this cultural paradigm shift in Canada has increasingly created an environment where individuals are encouraged to identify potential areas of error and seek solutions together.

  3. asamarth Says:

    The problems related to patient safety are even worse in developing countries. Developing countries lack in poor frame-work for implementation of patient safety methods. Physician hardly know what kind of patient safety methods have to be followed. There is no professional training of Physicians in patient safety. Hospitals are over filled with patients. The major challenge is too provide healthcare, hence patient safety takes up a back seat!

  4. gingershu Says:

    Sometimes, the cultural environment within hospitals also contribute to breaches in patient safety. Some doctors feel it is the responsibility of others to do the job while they take all the credit. I know this because I work with someone just like that!

  5. mansourfaisal Says:

    great topic indeed !

    In 1999, the Institute of Medicine (IOM) published the landmark report, “To Err is Human: Building a Safer Health System” which stated that between 44,000 and 98,000 hospital deaths are attributable to preventable medical errors each year, since that report and up to this day the area of patient safety has expanded dramatically. The highlight of this report was to eliminate the culture of blame in organizations and have a holistic systems approach that looks at structures, process, and outcomes.

    I agree that knowledge and training is crucial as you mentioned, but it is also of little impact if the organizational culture does not incorporate values of team work and patient safety in their practice.

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