A register of blunders or botchers?BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7251.1738 (Published 24 June 2000) Cite this as: BMJ 2000;320:1738
- Jane Smith
One of the classic tactics of “spin”—telling a story so that listeners hear the message you want to convey—is to preannounce a report and what you are going to do about it a day or two before the report comes out. That way you get your reaction in first, and, because no one else has read the report, the media describe it in your terms.
Alan Milburn, secretary of state for health, is a fine master of spin, and he showed his skills again last week over a report on learning from adverse events in the NHS by Liam Donaldson, England's chief medical officer (see pages 1683 and 1689). In the process, he obscured one of the key lessons for any organisation that is serious about reducing errors.
As An Organisation with a Memory (the report's evocative title) points out, adverse events in the NHS—indeed, any health system—are common. And most of them are not caused by bad individuals: “In the great majority of cases, the causes of serious failures stretch far …