“Re-cognising” risks: from space shuttles to chest drainsBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4393 (Published 13 July 2011) Cite this as: BMJ 2011;343:d4393
All rapid responses
During 2009 I spent a period of time in the NPSA interviewing staff
and observing their processes. I was enormously impressed at the methods
used to filter the 6000 adverse events notified by NHS staff each DAY and
by the quality of the multidisciplinary debates so well described by Tara.
Senior NHS staff surveyed in the same study were in no doubt that the work
of the NPSA had been extremely valuable in the development of safer
systems and any diminution in this work is likely to be to the detriment
of patients and staff.
Competing interests: Past research funding from NPSA
Reading Tara Lamont's paper was a bitter-sweet experience as it
reminded me of the good work that Tara and her NPSA colleagues have
undertaken on behalf of patient safety in the UK but also of the
dissolution of the NPSA in its present form. I have assisted the NPSA in
their inquiries into two areas of Respiratory Medicine (chest drains and
emergency oxygen use) where I was aware of unsafe practice on a systematic
basis throughout the UK and I believe that the rapid response reports from
the NPSA have contributed greatly to patient safety in these two areas as
well as many others.
Systematic risks to patient safety require a
coordinated systematic response because they are unlikely to be resolved
at a local level at hundreds of Trusts throughout the NHS. I very much
hope that the successor organization or organizations will continue to
campaign as effectively for improved patient safety as Tara Lamont and her
colleagues at the NPSA have done in the past.
Competing interests: Dr O'Driscoll is co-chair of the British Thoracic Society Emergency Oxygen Guideline development group.