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Should we publish our mistakes?

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Fantastic! Four days off that promises to have at least some sunshine and, boy, am I making the most of it. With a compass-reading cousin we are going to bag the most remote Munros – five isolated Scottish peaks over three thousand feet – and the trip will involve camping out for three nights and carrying all our gear and food up these summits.

I’m looking forward to the break from my acute Trust role as GP clinical director. It’s been a tough few weeks with relentless adverse publicity about my hospitals on the back of the Keogh review, snap inspections by CQC and a series of leaked revelations by one or more of my colleagues. The media coverage doesn’t upset me personally – we know what’s wrong and what to do to fix it – we know, like any health organisation, we can be better and need to make significant improvements. However I do feel for the staff and patients daily coming through the door walking past the newspaper hoardings, ‘dying shame of hospitals’ or ‘eight-hour wait for hospital bed’.

For a few days I will be out of radio, phone or e-mail reception in what, my cousin cheerfully tells me, is known as the Great Wilderness. We’ve got to drive north over three hundred miles – even though home is virtually on the Scottish border – so let’s just fill the tank and hit the road. As I walk back to the car reading the local paper, I had foolishly picked up when paying for fuel, I started to see red. The headline read: ‘Shock infirmary dossier catalogues near-misses, mistakes and delays.’ My cousin studied my expression briefly before taking the keys off me. ‘I’ll drive,’ she said.

Let me step back a moment and explain. One of my medical heroes is Don Berwick, and I hope you have already heard of him – he is the lead for our new national advisory panel on patient safety, previously the boss of the Institute for Healthcare Improvement, where he famously reminded Americans that their proud hospitals and healthcare systems were killing people at the rate of four jumbo jet crashes each week due to medical errors.

There was, and is, a real need for us to learn from more safety-conscious industries, such as aviation, oil, automotive and apply their philosophy to healthcare.

The first step is to recognise that to err is human. Mistakes will happen and then to design systems and training that minimise those risks and build in mechanisms that prevent harm happening. An integral part of this step is a culture change – if we want to be more open about errors and near-misses, we need to follow the Japanese car makers’ philosophy of kaizen, where every fault found is a jewel because it allows you to refine and improve your processes. So every Trust in every department has an error log and we foster an open attitude so it’s ok to say something went wrong or was a near miss. It’s how we get better.

But then someone decided it would be helpful to put the incident log in the public domain. On one level, that’s fine, and if it encourages patients to raise their own issues, it’s been productive.

However if it has the reverse effect on the staff and makes them feel it’s somehow not right to raise these issues, and they stop being transparent and frank with each other in their departments, then it has been dangerously unhelpful. If we are covering things up please blow the whistle loud and clear but if we are being open and honest with each other, sound a fanfare.

Dr Peter Weaving is the GP-clinical director for North Cumbria University Hospitals Trust and a GP partner in Carlisle. He has been writing the Diary series for Practical Commissioning magazine since 2007. You can read the archive of his posts here and send him a tweet via @PeterWeaving.

 

Readers' comments (5)

  • When Politicians. electricians, dentists etc etc publish their mistakes I will agree. Otherwise it is another level of scrutinisation that is open to Daily Mail misinterpritation

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  • People with 'learning difficulties' cannot learn from their own mistakes! Studying mistakes and learning from them is the key for greater understanding.

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  • he's lost me again! was that a yes we should publicise our jewels or no we should squirrel them away?

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  • I'd be guided by a wiser, higher power like,say..... the CQC......who seem to be in the news just lately.

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  • Good point, Anonymous 9:13am, I'm very happy for errors and performance to be published but leaking internal incident logs without explanation is unhelpful and may deter staff from recording and reporting incidents in the future.
    Peter

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