Wise before the eventBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1378 (Published 29 March 2010) Cite this as: BMJ 2010;340:c1378
- Geoff Watts, freelance journalist
When healthcare errors and patient safety make news, it’s usually for one reason: disaster. The wrong dose injected in the wrong place; the left kidney removed instead of the right; the wrong drug dose dispensed … and so on. So when two positive, proactive developments recently achieved media coverage on the same day it was not only a surprise; it was a reminder that there is more to the patient safety agenda than issuing apologies and trying to get wise after the event. But just how wise are we now before the event?
The two news making developments were quite different. One featured the anniversary of the introduction of airline style preoperative checklists that an international study1 had demonstrated as effective in reducing the error rate during surgery. The other concerned new National Institute for Health and Clinical Excellence (NICE) guidance2 on the wider use of measures to prevent venous thromboembolism in hospital patients. Both were soundly rooted in evidence of benefit, an attribute that might seem to guarantee their immediate and enthusiastic uptake. Not so—as recent revelations about the tardy response by some NHS hospital trusts3 to National Patient Safety Agency (NPSA) alerts have demonstrated.
Obstacles to change
A couple of hours spent browsing the literature of attempts to manage change intended to improve patient safety show some of the hurdles to be negotiated. Hurdles? But isn’t it all quite straightforward? A mistake is made. You find out how it came about and why, devise the best way to avoid repeating it, make the necessary arrangements, and then tell everyone what to do. As …