Francis Report 1
Will Francis be the 'sentinel' event that changes the healthcare culture in the UK to one of patient safety-centred learning? This is the big chance to really refocus and eliminate the old-fashioned views around working practice.
As an outside observer and trainer in healthcare for almost 11 years I have been amazed at the attitudes espoused by people from nurses to senior clinicians and above. It is as if nothing can be learned from safety-critical industries and this attitude is still highly prevalent. Thank goodness the number of enlightened individuals and in some cases, organisations is growing. I sincerely hope that the current impetus to change the culture of blame and over-regulation can build.
W hat does Francis have to say? "They will do everything in their power to protect patients from avoidable harm" - and how exactly does that translate to the real World? How does a HCA deal with a Doctor who tells him where to place his checklist? Will management support? Will non-adherence to safety tools be dealt with? It all sounds great but how? Not more regulation please!
We treat professionals as intelligent adults but I wonder if they have been treated not so for too long. Consider the 'mandatory' WHO-led Safer Surgery checklist. I believe the reason that it is incorrectly understood and therefore not properly used is lack of education. How many hospitals introduced the WHO checklist by email? Quite a few, and the result is we are invited in two years down the line to try and improve understanding and adherence to safety guidelines and procedures. Three hospitals in the last month, all of which have had recent serious incidents or 'never events'.
I have recently heard of an emergency ectopic pregnancy procedure carried out in the early hours where the wrong side was operated on. The problem of course had to be dealt with and the young mother is now unable to conceive ever again. Tragedy. The team said they would have used the checklist had it been daytime. Bizarre. The use of the checklist should be everytime such that it becomes 'the way we do things here' - everywhere. Another I heard of yesterday - injection in the wrong eye. What made that one so bad was the alleged statement by the clinican that it was 'just one of those things'.
We must not tolerate avoidable harm. There is simply no excuse.
We want to celebrate success. We want to hear when the team have insisted on the correct protocol whatever it is - checklist or not.