Intended for healthcare professionals

Analysis Essay

What went wrong with the quality and safety agenda? An essay by Michael Buist and Sarah Middleton

BMJ 2013; 347 doi: (Published 30 September 2013) Cite this as: BMJ 2013;347:f5800
  1. Michael Buist, professor1,
  2. Sarah Middleton, honorary senior lecturer2
  1. 1Centre for Health Services Research, School of Medicine, University of Tasmania, Hobart 7000, Tasmania, Australia
  2. 2Rural Clinical School, University of Tasmania, Burnie, Australia
  1. Correspondence to M Buist Michael.Buist{at}

Despite huge investment in quality and safety over the past two decades, healthcare is still failing to learn the lessons from its mistakes. Michael Buist and Sarah Middleton examine the reasons and call for a shift in medical culture

After attending the International Quality and Safety Forum in London in April this year, I returned to the intensive care unit where I work as a consultant to be greeted with those words we all dread, “Mike, you will never guess what happened.” I was given the brief case summary. For the rest of the morning, bit by bit, the events of the previous week—and only a week—were retold to me. It was a litany of missed diagnoses, poor (or no) communication, failure to follow established guidelines, and failure to follow expert advice. The net result? Two unexpected deaths, a preventable cardiac arrest, a traumatised intern, an emergency department director “at the end of her tether,” and my locum consultant cancelling his next locum shift.

I didn’t particularly want to hear any of this, but what I heard concerned me. Emboldened by the talk at the forum from Robert Francis, chair of the inquiry into poor care at the Mid-Staffordshire trust,1 I picked up the phone and called our chief executive officer, reciting the events and explaining my concerns. The chief executive was hugely empathetic, but then said those words that resonated from Francis’s talk, “They seem to have similar if not worse problems at ….” So, Francis was right: we don’t aspire to deliver the best clinical care; we aspire to keep our heads above the water by being not as bad as our colleagues down the road.

I remember sitting there in that massive auditorium, listening to that talk. As I listened, I had a growing sense of …

View Full Text

Log in

Log in through your institution


* For online subscription