GP.18.The National Patient Safety Agency (NPSA): campaign to raise awareness among doctors in training about what can be done to improve patient safety.

Campaign to raise awareness among doctors (England & Wales)

To encourage a more open debate about error, fourteen of the nation’s leading doctors have also contributed highly personal accounts of mistakes they have made. The document, entitled Medical Error, is available on safer health care. The Agency is calling on all doctors to report such problems so that the root causes can be addressed.

Research has consistently shown that doctors are less likely to report when things go wrong than other staff groups, either because they do not have time or do not feel they will be treated fairly. For example, a study on reporting with 65 surgical trainees in Hull and East Yorkshire Trust found that only 33% had ever reported an incident. The most common reason given for not reporting was that it was not in the doctors’ culture. Of those surveyed, 42% said they would report more if the system was anonymous. The NPSA has worked with the Medical Defence Union and Medical Protection Society to publish a new handbook for junior doctors which provides them with practical advice on how to reduce risk, and highlights the importance of reporting and the need to change systems to protect doctors from error. The publication is supported by the British Medical Association’s Junior Doctors’ Committee. A compli-
mentary copy will be sent to 43,454 of BMA’s junior members.

The vast majority of NHS care is safe and effective with over 1.000.000 - patients successfully treated every day.

However errors do occur and the NPSA collects reports from healthcare staff and patients, to identify recurrent patient safety problems and develop national solutions. If doctor’s report locally, the NPSA will automatically receive this information, however, they now also have the option of reporting anonymously online direct to the NPSA.

NPSA Medical Director, Professor Sir John Lilleyman said:

We know there are various reasons why doctors might not report an incident, including lack of confidence that they will be dealt with fairly. Yet the very best doctors can make mistakes, and these mistakes often stay with them throughout their working lives."

“We want to help protect doctors from error by changing the systems they are working in so that it is much harder, for example, for them to mix up two very similar drugs or confuse two patients with the same name whilst under pressure. We want more doctors to report locally or nationally to enable us to learn from what goes wrong and put the right safeguards in place. We understand that until doctors feel they are working in a more open culture, we will need to have an anonymous reporting system.”

Mr Simon Eccles, chairman of the BMA's Junior Doctors Committee, said:

"Doctors, in common with all other professions, make mistakes. Until now the prevailing culture in medicine has limited how much we have learned from other doctors' errors. This NPSA publication must help to foster a more open attitude. The best way to avoid repeating a mistake is to know about it and learn from that knowledge."

The NPSA has focused on a number of changes to the systems in which doctors work to improve patient safety, including:

• Standardising the hospital crash call number used to summon the resuscitation team. The NPSA found that 27 different numbers were in place which is confusing for staff on rotation and can cause delay.



• Improving the storage of potassium chloride concentrate, which if administered by accident can be fatal.



• The 'clean-your-hands' campaign that puts alcohol rub by the bed so that busy staff can clean their hands easily and reduce the spread of hospital infection.