Call for NHS Scotland to overhaul medical mistake procedures

In an operating theatre The professor said reporting mistakes made it easier for lessons to be learned

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The NHS in Scotland must adopt a "radically different approach" to how it deals with medical mistakes, an expert has warned.

Professor Peter Davey said a culture of fear prevented errors being reported and lessons learned.

He highlighted a pilot project in Tayside in which trainee doctors and medical students are encouraged to record adverse incidents.

It has led to a 17-fold increase in the number of reported mistakes.

The trainees and students are actively supported when they report errors, which are then reflected on and reviewed alongside senior colleagues so that lessons can be learned.

The intention is to provide a non-judgemental means of learning from the incidents so they are less likely to be repeated.

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The culture within the profession and the NHS has not encouraged the open reporting of mistakes”

End Quote Prof Peter Davey University of Dundee

Prof Davey, the lead for clinical quality improvement at the University of Dundee, said this was crucial in allowing future standards of care to be improved.

Data from the National Patient Safety Agency has suggested that only 10-15% of adverse incidents across the UK are currently reported by doctors.

Prof Davey said this was largely because the culture within the NHS discourages doctors from reporting errors for fear of having blame apportioned.

In contrast, the pilot has led to a dramatic increase in the number of adverse incidents reported by foundation year trainees in Tayside, from about five reports in 2005/06 to more than 90 in 2011/12.

'Quality improvement'

Prof Davey said the Tayside approach had much wider potential and should now be rolled out across Scotland.

He added: "Traditionally, clinical advice has been cascaded from senior consultants down to trainee doctors and medical students and the culture within the profession and the NHS has not encouraged the open reporting of mistakes.

"This model turns this on its head and is about the tremendous positive potential for trainee-led, or bottom up, quality improvement."

The professor pointed to the Francis Report into events at Mid Staffordshire, which highlighted the negative culture within the NHS, the need to put patients at the centre of care and the need for a range of quality improvements.

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Today's trainee doctors will be the consultants of tomorrow and the future of patient care in Scotland”

End Quote Dr Kerri Baker Scottish Academy Trainee Doctors' Group

The Royal College of Physicians of Edinburgh has recently highlighted the potential for these events to be repeated in any hospital in the UK, including Scotland, and called for the NHS to refocus on the quality of patient care.

Prof Davey said: "Trainee-led quality improvements as demonstrated in Tayside offer an innovative and potent method of doing this and it is important that the NHS engages and harnesses the potential of these doctors if we wish to improve standards of care."

The professor is due to speak at a conference on professionalism and excellence in modern medicine in Edinburgh on Thursday.

The conference has been organised to provide a focus for discussing how doctors, including trainee doctors - the next generation of consultants - can influence improvement in all aspects of medical care within the NHS.

Dr Kerri Baker, chairwoman of the Scottish Academy Trainee Doctors' Group, said: "Today's trainee doctors will be the consultants of tomorrow and the future of patient care in Scotland.

"As such, it is essential to instil in them the values, standards and practices that both patients and doctors aspire to for healthcare in Scotland.

"We must also aim to treat patients in a way that we would expect our own families to be treated when receiving care."

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