Practising safely in the foundation years
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1046 (Published 03 April 2009) Cite this as: BMJ 2009;338:b1046
All rapid responses
We welcome the authors' focus on the role of junior doctors in improving patient safety. Drawing on our experience of training healthcare professionals and managers in safety improvement, we would particularly emphasise the following points:
- training, hard work and diligence are necessary but not sufficient for safe care, and the ability to understand,measure and improve processes are an essential part of juniors' skillset
- junior doctors can be given the skills to lead patient safety improvement themselves, and, using the Model for Improvement and small scale tests of change any member of a team can achieve a great deal
- although at odds with the sometimes macho culture of medical training, appropriate standardisation of care (eg in care bundles) allows for greater reliability, and frees clinicians to concentrate on complex decision making
- safe and effective healthcare increasingly depends on high quality teams who are skilled in open communication, sharing of goals and expertise, and comfortable with flattened hierarchies. Junior doctors can play an important role in creating and maintaining such teamwork cultures.
The NHS Institute for Innovation and Improvement has trained teams of senior clinicians from over 70 hospitals in safety improvement methods. As we begin a programme to give junior doctors improvement skills, Long et al's article is a timely reminder of how influential this group can be in improving the safety of care for their patients.
Competing interests:
None declared
Competing interests: No competing interests
I recently attended the 2009 International Forum on Quality and
Safety in Healt, Berlin- Germany from 17-20th March and observed that
whilst error in care is universal, certain interventions to prevent or
reduce errors can be loaction-specific. In the paper by Susan Long, Graham
neale and Charles Vincent it is our experience that all the 'examples of
strategies that have been developed to reduce errors and subsequent harm'
apply globally. But in developing countries, like those in west africa,
additional strategies are worth mentioning such as measures to eliminate
herd-mentality and cover-up by care givers. The culture of 'protecting
ones colleagues', 'of denial and 'negativism', 'delusion of competence'
and reluctance to communicate truthfully with patients, family and next of
kin when errors occur, are too common. A key strategy to combat these
destructive traits is education, advocacy and support through centres of
'clinical governance, quality and safety', such as was successfully
piloted in cross river state of Nigeria between 2004-2008 and which had
started to result in positive change in attitude and behaviour of health
practitioners. The centre had as its Motto: 'protected patients, whilst
supporting health workers' and emphasized that BOTH parts of the motto
must be implemented together for a positive outcome to be achieved.
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None
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I read the article by Long et al (1) with great interest but felt
that several rather important points were not mentioned in the analysis of
events. The term 'patient safety' is not a magical new field that will
transform the way in which patients are treated, it is a gimmicky phrase
used to repackage old ideas in new clothes; a thorough and comprehensive
period of training before qualification as a doctor should see the newly
qualified well equipped to work on the wards and then to progress up the
medical career ladder.
Sadly recent changes to both the undergraduate and postgraduate
medical curricula have seen a disproportionate leaning towards more
fashionable contemporary issues such as medical ethics, health promotion,
evidence based learning and communication skills; at the same time the
fundamental basics have been left to rot in the back waters (2). Medical
students are not prepared for the practicalities of life on the wards as
they no longer have any time to learn as apprentices, their schedules are
filled with endless formal sessions with less focus on the basic sciences,
while the ward apprenticeship has been reduced to ticking off boxes in a
heavy paper logbook. The problems with postgraduate medical education are
massive with the over emphasis on non-clinical gimmicky subjects such as
'clinical governance' and 'risk management' predominating, while a
reduction in on call and general clinical exposure seeing juniors starved
of an opportunity to develop. Nursing training has been similarly
affected by this educationalist drive, meaning that nursing students are
spending more and more time writing reflectively and creatively, while
their general experience levels of life on the wards plummet.
It is time that we went back to basics in medical education. We need
to focus on a good grounding in the basic sciences and let students
concentrate on the basics of managing 'patient safety' which involves
taking a history, clinical examination, differential diagnosis,
formulating and instigating a simple plan of action for a patient. If the
educationalists continue to have their way I can see the day when students
will have weekly seminars full of politically correct buzz words on
'patient safety' but their pharmacology syllabus will have been trimmed
down to a mere one day interactive problem-based multidisciplinary love
in. Personally speaking I remember by Foundation 2 year teaching only too
well, there was barely a single session on anything clinical, the focus
was on the politically correct, and there was simply no room to learn
about anatomy, physiology or pathology.
In the case discussed by Long et al (1) I am sure that the Foundation
doctor in question would have been far less likely to have mismanaged the
patient's warfarin dosing if they had spent many weeks on the wards as an
apprentice to the medical team, I don't think seminars on risk management
or more checklists would have helped much.
1. Susannah Long, Graham Neale, and Charles Vincent. Practising
safely in the foundation years. BMJ 2009; 338: b1046.
2. A.Franklyn-Miller, E.Falvey, P.McCrory. Time to wind back the
clock? The Surgeon. April 2009 Vol 7 No 2.
Competing interests:
None declared
Competing interests: No competing interests
I have tremendous admiration for my medical colleagues and the
difficult and stressful job they do. In particular I sympathise with the
pressures on those in their foundation posts.
I would suggest that in addition to the excellent suggestions made by
Susannah Long, Graham Neale, and Charles Vincent, junior doctors should
also seek support from their pharmacist colleagues. Promoting the safe and
effective use of medicines is our raison d’être. We also sit outside the
medical and nursing hierarchies, which can be seen as an advantage to some
junior doctors when they are seeking advice.
I always speak to my new medical colleagues when they arrive on our
unit to explain that I am there to support them and make sure our patients
receive appropriate medication, not to wield a green pen and write
critical comments on their drug charts.
Competing interests:
None declared
Competing interests: No competing interests
A very brilliant article. Also brings up a very important issue. Now
that warfarin is mainly prescribed centrally by the anti-coagulation
nurses, junior doctors are getting less and less experience in prescibing
warfarin. When I first started it took me sometime and a few bleeps to my
SHO before I was confident in prescribing warfarin. However it is unlikely
that prescribing warfarin without an INR would be defendable in court.
It is also very unusual that a coagulation screen was not done on clerking
in the admissions unit which would have picked up an abnormal INR.
It is also interesting that a sub-dural haematoma was not considered in a
patient who has come in with acute confusion secondary to falls and is
also on warfarin.
Dr Sukitha Namal Rupasinghe
Previously Fy1 in Stroke Medicine
Competing interests:
None declared
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Dear Sir,
I was glad to read about your article regarding warfarin dosage which
I am sure has confused many junior doctors during their initial first few
months.
My comment mainly regards the choice of therapy for stroke prevention in
this patient. I note that this patient was on warfarin for atrial
fibrillation only and there is no mention of any metallic heart valves in
the history. One wonders whether it would have been more appropriate for a
90 year old patient with mobility issues and potentially at risk of
recurrent falls to have thromboembolic prophylaxis with aspirin therapy
only instead of warfarin anticoagulation?
Competing interests:
None declared
Competing interests: No competing interests
Simple advice for juniors regarding patient safety.
1. Patient safety and their well being must be your primary concern.
2. Always take a good history, examine properly, document clearly and
arrange appropriate investigation and act on the results.
3. Vital signs are very vital and in every acute patients’ these signs
should be documented and if abnormal act quickly and if not it can cost
patients lives.
3. Hand over the care properly.
4. If in doubt, ask for help. Never take risk with your patients.
5. Involve your patients in any decision making. It is they who got to
live with the consequences.
6. Value and respect your patients and always be kind and courteous.
7. Earn your patients trust and respect.
8. Learn the art of softer skills of being a good doctor, like
communication skills, team working, leadership skills, assertiveness
skills, time management and so on.
9. Understand and practice the GMC's duty of doctors
10. Beware - Medicine is a risky profession and your patients’ trust you
and their lives are in your hands. Learn clinical risk management, dealing
with complaints, dealing with litigations, clinical incident reporting and
learning, medical errors and how to learn lessons and most of all learn to
be always honest and sincere with your patients even when things go wrong
and you have made a mistake.
To err is human and not to learn from them or covering it up is a
biggest crime any doctor can commit.
Being doctor is the best profession and one which is valued and
respected by everyone. At times when you work in the NHS, it doesn’t feel
like that but always remember doctors are the most trusted profession in
this world and we got to live up to that trust.
Competing interests:
None declared
Competing interests: No competing interests
Authors response to rapd responses for "Practising Safely in the Foundation Years"
We were pleased to receive seven ‘rapid responses’ to our article.
It seems to us that, taken together with our paper, these provide a good
overview of the problems facing trainees in trying to ensure safe hospital
practice.
The contribution from Benjamin Dean is perhaps the most pressing.
One of us (GN) was trained in the manner that he suggests and then spent
several years stumbling along in clinical practice, learning within a
hierarchical structure in which senior doctors used ‘their experience’ as
the evidence-base and speaking with senior colleagues as their prime mode
of communication. We wish to make it clear that we of course agree with
Dr. Dean that a good clinical grounding is essential for junior doctors to
practice safely. However, we also believe that it is important that they
have an understanding of how and why things go wrong, and of the role that
they can play in avoiding adverse events. The first of the tips offered by
Robert Varnum and Kate Jones illustrates this - “training, hard work and
diligence are necessary (we think, essential), but not sufficient for safe
care.”
Dr Purmah and Dr Rupasinghe raise important clinical points. The case
we described in the article was a fictional case drawn from a number of
real events, designed to show how even the most diligent doctors can miss
important issues.
Sarah Jones reminds us of the importance of the work of clinical
pharmacists in preventing accidents – teamwork is vital (1), and the
kindly support of experienced professionals that she describes is
extremely valuable to (and appreciated by) those starting out.
Dr. Ana’s description of the centres of “clinical governance, quality
and safety”, piloted in West Africa, remind us of the importance of
attitudes and ethos in developing and maintaining safe practice.
The simple advice for junior doctors given by Umesh Prabhu reflects
the valuable contribution he has made to improving patient safety, and
supplement our suggestions.
We hope that our brief contribution will have stimulated local
discussion as well as having led to these relevant contributions to the e-
mail columns of the BMJ.
References
1. Olsen S, Neale G, Schwab K, Psaila B, Patel T, Chapman EJ, and
Vincent C
Hospital staff should use more than one method to detect adverse events
and potential adverse events: incident reporting, pharmacist surveillance
and local real-time record review may all have a place.
Qual Saf Health Care 2007; 16: 40-44.
2. Fabri PJ, Zayas-Castro JL Human error, not communication and
system, underlies surgical complications. Surgery 2008;
144(4): 557-65.
Competing interests:
None declared
Competing interests: No competing interests