Notes on a Safety Button

Motivation

Last month, May 2007, random unannounced hygiene inspections were introduced in the NHS. In July 2005 the first NPSA report counted 840 lethal accidents reported by hospital staff, but Jarman et al estimated 40,000 from Hospital Episode Statistics. Today the big picture is substantially unchanged and accounts for appalling NHS staff moral produced by the tradition of mutual "cover-ups". In August new junior doctors will be initiated into their hospitals. Staff have called this the "Killing Season", where junior doctors get their "00" licence. So staff still can't be kept clean: Harriet Sergeant writes (Sunday Times 24/6/07).

From the PPIF0 website "Accident statistics unbelievable" (2005)

Last year the Times told us "blundering kills 40,000" patients per year, from a Dr Foster report in BMJ vol 329 August 2004 "How often are adverse events reported in English hospital statistics?". This month the Times tells us deaths due to accidents are down to 840 patients, from "Building a memory: preventing harm, reducing risks and improving patient safety" by the National Patient Safety Agency (NPSA). But reporting is not mandatory with only eighteen Trusts providing useable data. Guardian reports.

Patients agreeing to be treated expect doctors to do their best. They expect failure to report an accident to be a sackable offence.

Will Forums have to make police style anti-terrorist raids to inspect hospital mortuaries for the profession take this seriously? Comparing the death certificate with the results of randomly chosen post mortems could give a truer picture of the situation than we currently have. Analysis of pollutant toxic burden should be routine after death.

The NPSA definition of an adverse incident here is very narrow. In June the Public Accounts committee warned about the NHS "fog of ignorance" and estimated the deaths from hospital acquired infections to be 5,000 per year. The MRSA Support Group suggests deaths may be nearer 20,000 per year. Rath puts death from mistakes as the single highest cause of death in US hospitals. Scaling Rath's figures for UK suggests 150,000-200,000 deaths involve medical mistakes: medical nemesis indeed. Safety is not a matter for fudging like this.

The VSM algedonic solution

Within the VSM methodology the Safety Button produces an alert- an escalating "algedonic" feedback. A simple button on a telephone could initiate the reporting of a mistake. Simple ergonomics are essential. Sir Brian Jarman (founder of the "Dr Foster" Unit at Imperial College, London) has suggested staff reporting negligence, if non-criminal, should be immune from liability if reporting is prompt.

R.N.G. 16 June 2007

Reference

Vast costs, progress and problems with NPfIT House of Commons Committee of Public Accounts Department of Health: The National Programme for IT in the NHS 26 March 2007

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