About this slideshow

This presentation was given by Professor Mary Dixon-Woods from the University of Leicester at our 'Ideas for change' conference on patient safety, in December 2014.

Further reading

Safer Clinical Systems

Developed as a five year phased programme, Safe Clinical Systems helps health care teams proactively identify potential safety breaches, enabling them to build better, safer health care systems.



Dr. Eva Fresco

Dear Prof. Mary - Dixon Woods,

Before I even opened your presentation, ( friend sent me here to get some knowledge about human factors in healthcare and how it can be thought to the juniors ) .. I kept thinking : " I am not sure if I really want to do this and if this is the right thing for us - as 1. The system is too bureucratic 2 . there are too many guidelines across the Trusts which vary from one place to another 3. On your rotation , you end up learning and re- learning guidelines / local rules which leaves your brain overloaded with unnecessary information ( and hence less place left for the really relevant clinical stuff and subsequently more likely to do a serious mistake ) , 4. the system is not see - through, 5. the relevant parts do not communicate with each other..5. nurses spent more time documenting then looking after the actual patient 6. even when encoutered the problem, we need to - in quite a complicated way " report the problem" , and apart from local investigation we actually have independent teams and organisations to investigate whether the team has been investigated properly.

I have been working within the UK for 10 years, in 5 different hospitals, and unfortunately I have to say that where I come from ( overseas/ Eastern Europe ) - we didn`t have local guidelines ( only several very simple ones - on how to deal with medical gases , where are the fire escape routes etc ) - The rest of guidelines were simple and universal across the whole country ( e.g. sepsis management, community acquired pneumonia management , major haemorrhage protocol, indication for renal replacement therapy or ACS protocol, etc) . No other guidelines / intermediate guidelines were needed. The nurses would document their observations, but didnt have to write lenghty documentation on how the patient is.
Still the work would have been done in a timely manner and the emergencies would take priority and acute cases operated on within a very short time scale ( usually 2 hours).
I think we should focus more on how to get things done then how to proof that things have been done.

In your presentation you were exactly speaking my mind - and I believe all of us - NHS emplyees would be most grateful to you and the people in your team for striving to implement such changes.

I believe there must be the way how to make the whole system simple and hence more "user friendly ".
The best solutions are always the most simple ones - just sometimes we don`t see them

I wish you the best of luck - once again, thank you for all your wonderful work - and if there would be any way how I could help , I would be most happy to help.

P,S, From my experience , people from South African Health Care system have quite often good experience and talent on how to sort out complex problems - how to focus on the most important .

Thank you very much, kind regards,

Dr Eva Fresco,
ICU St Peter`s Hospital,
Chertsey, Surrey

Add new comment

* indicates a required field

Your email address will not be published on the site and will only be used if we need to contact you about your comment.

View our comments policy