Senior doctors admit mistakes in campaign for more open culture
http://www.100md.com
《英国医生杂志》
More than a dozen senior British medical figures have publicly owned up to past clinical errors as part of a campaign to encourage other doctors to report incidents and improve the safety of patients.
The doctors have contributed their stories to a handbook for junior doctors, published last week by the National Patient Safety Agency.
The agency is calling on all doctors to report mistakes so that the root causes can be addressed. Research has shown that doctors are less likely than other health professionals to report when things go wrong because they do not have time or do not feel they will be treated fairly.
Graeme Catto, president of the General Medical Council, is one of 14 senior doctors who gave a personal account of a medical error. As a general consultant physician he missed the fact that a patient had a blood infection. The man developed meningitis and died.
Professor Catto said the mistake "will always live with me" and that he had learned the need to pay endless attention to detail.
Other contributors include James Johnson, the BMA chairman, Carol Black, president of the Royal College of Physicians, and the editors of the BMJ and the Lancet.
The agency's medical director, John Lilleyman, said steps had been taken to make the patients discussed in the anecdotes unidentifiable. "These incidents happened in the distant past, and it is unlikely any patient will recognise themselves. There is a small risk, but it was one we were prepared to take. The verisimilitude gives impact. We wanted to emphasise that if you do something wrong you should put your hand up."
The handbook, Medical Error, tells doctors that as well as reporting an incident locally—in which case the report automatically goes on to the National Patient Safety Agency—they now also have the option of reporting directly but anonymously to the agency (http://npsa.nhs.uk/staffreports).
Professor Lilleyman added that some doctors did not report an incident because of a lack of confidence that they will be dealt with fairly. "We understand that until doctors feel they are working in a more open culture we will need to have an anonymous reporting system."
Stephen Green, head of risk management at the Medical Defence Union (MDU), said: "Our members often tell us of the terrible distress they feel when they make a mistake. They are often surprised to learn that a significant proportion of incidents reported to the MDU can be traced back to lack of procedure or systems failing, rather than to lack of individual clinicians' knowledge. It is vital that we learn from incidents and near misses."
To improve patient safety the National Patient Safety Agency has focused on a number of changes to the systems that doctors work in, including asking NHS acute trusts to standardise the "crash call" number to 2222.(Rebecca Coombes)
The doctors have contributed their stories to a handbook for junior doctors, published last week by the National Patient Safety Agency.
The agency is calling on all doctors to report mistakes so that the root causes can be addressed. Research has shown that doctors are less likely than other health professionals to report when things go wrong because they do not have time or do not feel they will be treated fairly.
Graeme Catto, president of the General Medical Council, is one of 14 senior doctors who gave a personal account of a medical error. As a general consultant physician he missed the fact that a patient had a blood infection. The man developed meningitis and died.
Professor Catto said the mistake "will always live with me" and that he had learned the need to pay endless attention to detail.
Other contributors include James Johnson, the BMA chairman, Carol Black, president of the Royal College of Physicians, and the editors of the BMJ and the Lancet.
The agency's medical director, John Lilleyman, said steps had been taken to make the patients discussed in the anecdotes unidentifiable. "These incidents happened in the distant past, and it is unlikely any patient will recognise themselves. There is a small risk, but it was one we were prepared to take. The verisimilitude gives impact. We wanted to emphasise that if you do something wrong you should put your hand up."
The handbook, Medical Error, tells doctors that as well as reporting an incident locally—in which case the report automatically goes on to the National Patient Safety Agency—they now also have the option of reporting directly but anonymously to the agency (http://npsa.nhs.uk/staffreports).
Professor Lilleyman added that some doctors did not report an incident because of a lack of confidence that they will be dealt with fairly. "We understand that until doctors feel they are working in a more open culture we will need to have an anonymous reporting system."
Stephen Green, head of risk management at the Medical Defence Union (MDU), said: "Our members often tell us of the terrible distress they feel when they make a mistake. They are often surprised to learn that a significant proportion of incidents reported to the MDU can be traced back to lack of procedure or systems failing, rather than to lack of individual clinicians' knowledge. It is vital that we learn from incidents and near misses."
To improve patient safety the National Patient Safety Agency has focused on a number of changes to the systems that doctors work in, including asking NHS acute trusts to standardise the "crash call" number to 2222.(Rebecca Coombes)