Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
nhs bureaucracy affects patient safety
- David H.S. Reid (6 July 2009)
-
Finances and targets ahead of quality and safety
- David Levine (13 July 2009)
-
Prolonged timescales for the introduction of safety-critical new medical technologies may be inevitable
- Philip J Bickford Smith (13 July 2009)
-
Patient safety: a work in progress
- Benjamin W Lamb, Kamal Nagpal (16 July 2009)
|
|
|||
|
David H.S. Reid, Consultant Paediatrician Retired
Send response to journal:
|
Recently, I developed an urgent life-threatening condition. In January 2009 I was referred by my GP to see a Consultant in hospital X. My appointment to see this Consultant has never occurred. On two visits there, I never saw him. After many months I lost confidence in hospital X so I asked my long-suffering GP to refer me to see a Consultant in hospital Y. After six months I have not yet seen a Consultant. I have two questions: 1. As a former consultant myself, I used to be phoned by GPs to see urgent cases right away. Apparently, the NHS bureaucracy has stopped this from happening. Why? 2. If one is promised, as a patient, to see a named Consultant why or how can the Consultant remain absent? Is the Consultant not the gold standard? How can such specific promises be abandoned to suit the NHS bureaucracy? Competing interests: None declared |
|||
|
|
|||
|
David Levine, Retired Physician Penzance, Cornwall TR19 7AX
Send response to journal:
|
Here we go again! MPs and other politicians are quick to express shock and distress that the NHS puts finances and targets ahead of safety and other aspects of clinical quality. All MPs know well that it has been politicians themselves who have dictated that NHS Trusts put finance and nonsense targets ahead of safety and real quality. Because they don't know how to measure most truly important things they use inappropriate proxy measures - the 4 hour accident and emergency wait is just one good example- and pretend to the public that they have set a clinically meaningful target. Complaints from clinicians and enlightened managers that such policies cause harm are ignored. Because politicians don't want to be seen personally as the cause of the problems they devolve enforcement down the line, primarily to Strategic Health Authorities who make clear the dire consquences to Trusts if the political targets are not met. Clinicians and most managers would readily put safety and true quality above the false targets but the bullying and intimidation they receive means that huge amounts of time are spent chasing the wrong things so that 'good news' can be passed up the line. In the last decade of my work in an NHS trust I saw many good managers terrified by the perceived consequences of patients waiting a minute over 4 hours in an emergency department, even though the patients were receiving good care and when movement quickly to the wrong place would have been hazardous. Any MP thinking that bullying is banned from the NHS should take the trouble to see personally how intimidation from high level is destroying staff morale at the sharp end. Similar examples of inappropriate attention to targets can be found in the way continuity of care has been sacrificed to other dictats but clinical concerns from staff for patients fall on deaf ears. There is no shortage of incident reports; the problem is that acting on them is hampered by imposed bureaucracy. Perhaps instead of the bleating question 'who allowed these problems to happen?' there could be recognition that it is often MPs themselves who have failed to be sufficiently honest. A 'wise before the event' committee would be a wonderful innovation but the current level of political ability and integrity might preclude a quorum. Competing interests: None declared |
|||
|
|
|||
|
Philip J Bickford Smith, Consultant Anaesthetist Bradford Teaching Hospitals NHS Foundation Trust,, West Yorkshire BD9 6RJ
Send response to journal:
|
Jacqui Wise’s report1 of the House of Commons Health Committee’s Report on Patient Safety2 mentions the alarm expressed by MPs regarding the time taken for the introduction of luer-incompatible spinal needles, to help avoid fatal ‘wrong-route’ injections into the spine. In 2001, I commented that, due to perceived resistance to change from within the medical device industry, financial and political support would be needed to effect such a change3. The Chief Medical Officer responded to expert recommendations on the development of non-luer spinal systems4, 5 by establishing a multi-disciplinary group, involving several governmental and non-governmental agencies, clinicians and academics. In April 2002, an ‘Invitation to Supply’ was placed in the Official Journal of the European Communities6 by the NHS Purchasing and Supply Agency, asking manufacturers to supply luer-incompatible spinal needles and associated devices. A comprehensive series of evaluations of the several systems submitted subsequently took place. A prospective analysis of potential hazards rising from the introduction of non-luer spinal systems was also carried out7. The selected design was modified in response to feedback from clinical and simulator tests which were funded by the Department of Health (DoH). Further testing then took place across a range of clinical disciplines, including anaesthetists, haematologists, paediatric oncologists and pharmacists. The results8 prompted further refinements and the preparation of design proposals for an international standard. This step-wise approach was predicated by the potential for creating new hazards: The introduction of a luer-incompatible system without a simultaneous and rigorous system for training and informing all potential users of the change. Whilst at least one range of non-luer spinal and epidural products is now available, the engagement of the diverse NHS professional organisations has yet to be achieved. The Neurax® connector design9, now incorporated into a range of medical devices and evaluated on behalf on the DoH, was developed by NHS- employed innovators - not by any company within the established medical device industry. The reasons for this will have to be answered by the industry’s representative organisations. This has inevitably meant that progress with the development has been slower, than if this initiative had been backed by the resources available to a multi-national enterprise, of which there are several in the field. The expansion of the design brief to include a means to prevent deaths from epidural medication misconnection, as occurred in Swindon in 200410, introduced further delay. Implied criticism of the NHS by the Health Committee is thus premature and misdirected. A safe introduction of a new non-luer system requires a co-ordinated support from Government, Royal Colleges, NHS organisations including the Supply Chain and medical device manufacturers. The Medicines and Healthcare Products Regulatory Agency, The National Patient Safety Agency, and DoH Patient Safety Team would seem to be best- placed to coordinate this. I am confident that, given the extent of the work done so far, if this initiative is now supported at the appropriate level in all relevant areas, the introduction of this safety technology to eliminate wrong-route spinal injections can be achievable within a far shorter time-frame than has elapsed since this issue first arose. (Competing interests: Philip J Bickford Smith is Director of B-Link (UK) Ltd, a private company developing small-bore medical connectors, including the Neurax system). Philip J Bickford Smith
References 1. Wise J MPs attack NHS for putting targets ahead of patient safety BMJ 2009;339:b2706 2. The House of Commons Health Committee Patient Safety- Sixth Report of Sessions 2008-09 London: The Stationery Office, 3rd July 2009 3: Bickford Smith PJ Designing safer medical devices requires financial and political support BMJ2001, 322:548 4.Department of Health. External Inquiry into the averse incident that occurred at the Queen’s Medical Centre, Nottingham, 4th January 2001 by Prof. Brian Toft London: Stationery Office, 2001 5. Department of Health. The Prevention of Intrathecal Medication Errors – A Report to the Chief Medical Officer. Professor Kent Woods. London: Department of Health 2001 6. Official Journal of the European Communities - Supply contracts - Restricted procedure UK- Chester: spinal connectors 2002/S 66-051750. http://www.ojec.com 7. PS/038 - A prospective hazard analysis and pre-implementation evaluation of non-Luer spinal connectors. http://www.pcpoh.bham.ac.uk/publichealth/psrp/PS038_Project_Summary.shtml 8. PS/049 Pre-Implementation Evaluation of Non-Luer Compatible Spinal Equipment http://www.pcpoh.bham.ac.uk/publichealth/psrp/PS049_Project_Summary.shtml 9. http://www.neurax.co.uk 10. http://www.timesonline.co.uk/tol/life_and_style/health/article3314183.ece Competing interests: Philip J Bickford Smith is Director of B-Link (UK) Ltd, a private company developing small-bore medical connectors, including the Neurax system mentioned here |
|||
|
|
|||
|
Benjamin W Lamb, Clinical Research Fellow Imperial College London, London, W2 1PG, Kamal Nagpal
Send response to journal:
|
We welcome the Sixth Report of the Health Committee on Patient Safety. The committee appear to have recognised the priority that has been given to patient safety in recent years, but also highlights that services are safe enough yet1. One area that we feel the report has misjudged is the suggestion that more emphasis should be placed on serious events with less attention to common events. The tragic case of Wayne Jowett, who received a fatal injection of an anti cancer drug at the wrong site is given as an example. However, research has shown that less than 30% of adverse events result in death or severe injury2. Common and minor events should be taken seriously - the analogy of an iceberg may be appropriate with the burden of the morbidity lying below the surface. Furthermore, the root causes of all adverse events including ‘near- miss’ situations, have the same underlying patterns of failure. High reliability industries, such as the aviation industry are well known for treating near-misses and minor adverse events with as much rigor as those that result in death or permanent disability. By addressing near-misses and minor adverse events, the underlying causes can be corrected before they lead to a disastrous incident3,4. The report states that systematically reviewing samples of patients’ case notes at periodic intervals should be undertaken to record data on adverse events. However, there is evidence that more intensive investigation, including discussion with healthcare professionals, gives a higher yield of information on these events5. Addressing and improving patient safety is an ongoing process that needs to be embedded in the culture and practices of the NHS6. Progress has been made, but there is much more to do. Benjamin Lamb MRCS
The authors have no competing interests to declare. 1. Patient Safety, Sixth Report of Session 2008–09, Volume I. Department of Health. 18 June 2009 2. Brennan TA et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991 Feb 7;324(6):370-6. 3. Reason, J. T. (2000). "Human error: models and management". British Medical Journal 320 (7237): 768–770. 4. Gambino R, Mallon O. Near misses an untapped database to find root causes. Lab Report 1991; 13: 41-44 5. Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:2934. 6. Long et al. Practising safely in the foundation years. BMJ (2009) vol. 338 pp. b1046 Competing interests: None declared |
|||