Patient Safety, USA National Whistleblowing Centre

I decided to have a Patient Safety page on my website, so please have a look at this. Most of the articles are meant for health care professionals, but you may find some there of interest – e.g. there is an article by a medical student who compares safety measures when rock climbing with safety measures in clinical settings. The reasons I added a Patient Safety page were several – I have always been interested in how I can use my expertise and experience in Psychology to understand and improve the world around me. Thus, it is important to understand how doctors, nurses and others perform and behave in clinical settings. There is also a link between the culture of a hospital and patient safety – the quote on the front page of my website from the Harvard professor, Lucian Leape, sums it up well – A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect.

It so happened that around this time, Tuesday October 23, a Patient Safety meeting was organized by the Clinical Human Factors Group. This group was set up a few years ago by Martin Bromiley, an airline pilot whose wife sadly died as the result of medical mismanagement. He was appalled when he subsequently found out that simple safety measures, as are common in the airline industry, were not present in healthcare settings, and so he set about creating the Clinical Human Factors Group. It has done marvellous work over the years, and is influencing government thinking on patient safety, so hats off to Martin Bromiley for doing such a brilliant job! I had in fact been in touch with Martin a few years ago shortly after a radio programme was broadcast about his wife’s case, but with all the upheaval surrounding my dismissal I had not been in touch since then. I decided therefore to attend this meeting, partly out of my interest in patient safety and partly also to support the wonderful work that he and his colleagues are now doing.

It just so happened that the meeting was being held at my former workplace, Addenbrooke’s Hospital in Cambridge, so I had mixed feelings about going back there. As I walked through the hospital, some traumatic memories came back, but I mostly coped well. The opening address for the meeting was given by the medical director at Addenbrooke’s. He started by talking about recent ‘Never Events’ at Addenbrooke’s (‘very serious events that should never have happened’) and how Addenbrooke’s had lots of these events in recent years. He was quite apologetic about this, and I admired him for that.

The meeting itself was excellent, with lots of stimulating talks. There was one talk by Dr Nick Toff, advisor at Addenbrooke’s, who also happens to be a pilot, and he gave a very good overview of patient safety and Never Events. He has written an article comparing aviation safety and medical safety, and this is his paper (Download PDF File). At the meeting, there was an opportunity to have Poster Displays about patient safety, and I had a display on my Smart Papers diagnostic guidelines – this is my Poster Display (download PDF File).

At the meeting, the Clinical Human Factors Group produced a ‘Manifesto for Change’, which incorporated three programmes of action –

1. Human factors education and training

2. Building ‘high reliability’ organizations

3. Intelligent regulation and independent investigation

The third of these goals would address some of the management issues highlighted in this website.

The next day, Wednesday October 24, I gave a radio interview in response to a request from the USA National Whistleblowing Centre. That Centre has a weekly radio programme that is broadcast on an online radio channel, and they were interested to hear of my story, and in particular my hunger-strike. It is only when I described everything that I have gone through that I realised it brings back memories of unpleasant and traumatic events, and surprisingly I find it more upsetting when describing the events than I was when the events actually took place. I suppose there must be a good psychological explanation for this – I think at the time, you put yourself into ‘survival mode’ and shut-off any feelings you may have so that you cope as best you can, whereas when you look back, you have more time to reflect and are more aware of how traumatic and upsetting it all has been.

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