NHS managers were challenged to make patient safety a priority throughout the health service, at the NHS Confederation annual conference yesterday. The issue was raised in a keynote speech by Chief Medical Officer Sir Liam Donaldson.
While claiming that substantial progress had been made in recent years, Sir Liam acknowledged that the UK still has a long way to go to close the gap with international best practice. He highlighted the example of wrong site surgery, which he said was a test of the credibility of the health service.
“One thing that challenges us greatly with the media and the public is the incredulity they have that some of the things that go wrong can’t be stopped,” he said. “A classic example is wrong site surgery. It’s not common, but it is a risk which we don’t seem to have eradicated. When people see an error like this repeated, it causes a massive loss of confidence.”
Sir Liam called for a fundamental culture change in the NHS, to allow it to pass what he called ‘the orange wire test’. “I imagined that in the centre of the engine of an aircraft there would be an orange coloured wire,” he explained. “And that the engineer doing the pre-flight inspection had spotted a problem with that wire and corrected it. This being the airline industry, an alert would be put out and over the next 48 hours, all the engines of that kind around the world would have been inspected and all the planes would be safe to fly.
“That’s my dream for healthcare,” Sir Liam continued. “To get to the point where local learning, identifying the source of risk that could affect thousands or millions of patients, is transmitted. And not just across the same city, or the same country but right across the world.”
Later in the day, Chief Executive of NHS Tayside Gerry Marr, explained how his hospital was improving patient safety through the Health Foundation’s Safer Patient Initiative. “Leadership must make patient safety a key focus of attention in everything we do,” he said. “We concentrated on the issues of waste, variation and harm and made small tests of change in a clinical area, as close to the patient, the nurse and the doctor as possible. As a result, we’ve seen our adverse event rate fall by 71 per cent.”
Finally, Health Foundation Clinician Scientist Fellow Edwin Jesudason discussed the importance of matching leadership training and education with patient outcomes, in order to improve patient safety.
“Without feedback from outcomes and patient experience, how are we going to tackle the healthcare problem that is patient safety?” Edwin asked, before quoting Sir William Osler, who said in the 1890s: “If you listen carefully to the patient, they will tell you the diagnosis. He who studies medicine without books sails an uncharted sea but he who studies medicine without patients does not go to sea at all.”
Edwin suggested that you only had to change the words ‘studies medicine’ to ‘manages healthcare’ to see how relevant the message still was, over 100 years later.