Nhs reforms – what you should know

It will not have escaped your attention that the NHS is undergoing significant reforms. You may think that what is happening is irrelevant, but it is going to impact on the type of health service you will be working in. Whilst you don’t need to know the detail (trust me it is really boring and there is a lot of jargon to understand), it is instructive to see how the debate is being constructed. I’ve posted two tweets citing articles from Ben Goldacre who writes the Bad Science column in The Guardian. He makes some interesting points about the selective use of statistics by government ministers. Check out the editorial in the BMJ that he refers to as well.

Mistakes that I have made

The incident that I will reflect on involved a prescribing error in a 20 year old male psychiatric in- patient. He was being treated for a respiratory tract infection by me at a mental health hospital general clinic. The patient had a history of sleep and wake apnoea, severe obesity and schizophrenia (for which he was currently taking clozapine).

I had initially prescribed amoxicillin for his infection but this had been ineffective. When I saw him a week later, he was still not better and I decided to prescribe erythromycin as a second line treatment (erythromycin and clozapine in fact dangerously interact to increase the risk of seizures). My mistake had been noticed by an auxiliary nurse also present at the clinic, but she had not raised this concern at the time (after all, I am a Professor and I must have known what I was doing!). Only two days later when my colleague was reviewing the patient did the nurse reluctantly point out the error. Interestingly, even the hospital pharmacist who was dispensing the medication failed to pick up the error.

Patient safety in primary care

One of my research interests is patient safety in primary care. Patient safety incidents are an important and widespread problem in primary care. If we use a common definition of a patient safety incident (any unintended or unexpected incident which could have or did lead to harm for one or more patients) then evidence from the literature suggests that potentially there could be anywhere between 37-600 patient safety incidents per day in the NHS). Fortunately, most of these incidents will have very little consequence – they could be errors of process, for example, a misfiled result, a missing discharge letter from hospital. They could be errors of omission, for example a patient who should be on a drug but isn’t. Or they might be something more serious such as a delayed diagnosis or even a misdiagnosis which may result in harm.

The point is that many things can go wrong in general practice and some of them may have serious consequences. Trying to improve patient safety can be fraught with difficulty. Where does one start?

When things go wrong, there is a tendency to blame people. However, our understanding of patient safety shows us that quick assumptions and routine assignment of individual blame do not get to the heart of the problem. There are many underlying causes which contribute to patient safety problems and in the majority of cases these extend beyond the individual or the team.

To show you what I mean by this, I am going to tell you about a patient safety incident that involved me. Yes, just like anyone else, I can make mistakes and sometimes those mistakes can have serious consequences. The important thing is to be open about what has happened, understand why it happened and make sure that learning takes place…..

(My thanks to my medical student, Javed Naqvi,  from UCL who wrote up this incident)

Some pithy advice to graduating medical students

This is the edited text of a speech that I gave to graduating medical students in July 2010. Many have asked for a copy so here it is….

Three years ago I stood in front of an audience similar to this and my message was one of optimism. We had never had it so good. The University had completed a major capital building programme, our merger had been hugely successful and our graduates were entering a world where their skills were highly sought after.

Yet in the space of a few years everything has turned upside down. Although you are protected as graduating medical students, your colleagues in other disciplines are entering an external environment where graduate unemployment has been the highest for over 20 years. We as an institution are facing cuts of at least 25% form one of our main funding sources. Many of you will have read that it is likely that tuition fees may rise to levels that will make it very difficult for you to consider a University education for future generations – perhaps even putting studying for degrees like medicine out of the reach of everyone except the richest. I am sure that all of you feel that we face an uncertain future.