4 ms·

Absolute hero. The NHS tried their hardest to be as negligent as possible with my wife. I'm sorry that your wife had poor care - nobody should have to go throu

Absolute hero. The NHS tried their hardest to be as negligent as possible with my wife. I'm sorry that your wife had poor care - nobody should have to go through that. But isn't the approach you've described exactly what we want to avoid in a healthcare system? Blame is almost poisonous in its ability to encourage people to cover up the truth, "misplace" documents, make excuses, and so on - this often actively hinders improvement. Applying the principles of air accident investigation to the NHS is absolutely something I applaud, because the focus should be on why accidents happen, and how they can be prevented — not on who is responsible for them, outside of the most egregious cases of professional failure. Most medical professionals are competent and skilled, and really try rather hard to avoid causing harm to their patients. But mistakes and accidents will always happen regardless of this. I'm actually very surprised that such a system isn't already in place in the UK. We've already got an independent body which investigates rail accidents, for example - the RAIB looks into all major irregularities or failures on the UK rail network, and rather than finding fault, identifies root causes for failures. That often includes things like the design of systems to reduce the possibility of human error, or even such things as shift patterns which risk causing sleep deprivation. They then issue recommendations for improvement to different bodies as required, and I think they have some legal clout to follow up if they're not implemented. It seems like a system similar to that would be effective applied to the NHS, but I'm very cautious of heading down the same litigious route as the US.

paulhauggis 12y ago
"Most medical professionals are competent and skilled, and really try rather hard to avoid causing harm to their patients. But mistakes and accidents will always happen regardless of this." I don't know if I believe this. I have found many medical professionals (not all of course) to be arrogant and cocky and even if you pointed directly to the cause of the problem, would most likely not think that those rules apply to them. "not on who is responsible for them" Mistakes happen because of people. If there isn't some sort of punishment or blame, the majority of people will just continue on with what they are doing (and the mistakes will continue to happen). We need to blame people, so they change their behavior and have less accidents in the future. We also need to know why it happened. "Blame is almost poisonous in its ability to encourage people to cover up the truth" If someone covers up the truth, they should be fired immediately. I honestly don't want someone like this working anywhere near the medical field..and neither should you. Children cover up their mistakes and lie..adults own up to their problems and admit when they made a mistake. Also, the reason pilots have less mistakes is because a computer pretty much does 99% of the work. This is not the case with surgery and medicine. Humans still do most of the work.
- ISL 12y ago
  Mistakes happen because of people's errors, not 'because of people'. To blame a person, rather than their actions, is to alienate them. You want everyone on your team to be focused on quality outcomes, not on avoiding blame.
  - pling 12y ago
    The NHS currently runs on avoiding blame which is the problem. When someone is made accountable and the first thing they do is establish a process to avoid blame then you need to ask the question: do these people have my best interests at heart or are they avoiding being accountable? On many occasions the outcome is to avoid a breach rather than to fix a problem.
    - ZoFreX 12y ago
      The NHS also runs on overworking its employees and assuming they will still be effective at the end of a 20 hour shift with no sleep. If anyone making a completely understandable mistake due to the terrible conditions they have to work in is blamed and fired for it, would that really help? I think it's understandable for people to cover their own ass if they are expected to be infallible even under poor conditions - everyone else is doing it, if you don't the only difference it makes to the NHS is that it's down one employee. This is just one way of many possible ways that what might first appear to be a single human failing is down to a larger institutional problem.
      - pling 12y ago
        No they don't. That's the nursing unions and the press talking. It's total bollocks. The decision makers and the senior staff have considerably smaller shifts. With respect to the surgical and anaesthesiologist staffing, most of them (80%+) are contracted out and are private staff working on contract to the NHS now. A surgeon for example will probably spend two days a week on NHS cases, one day being surgical and the other being consultant and that's all you see of them. The remainder of the time is lucrative private care and occasionally teaching (which is well paid as well). There are a few exceptions to this i.e. StR's and consultants who seem to migrate into a speciality then leave after a few years. They all take the extra shifts because they're paid for the privilege of up to a 50% bonus. They're overworked because they're chasing the cash. The REAL overworked staff are mainly the support staff i.e nursing, supply, logistics. Most of them are contracted out now as well in the larger PCTs. Even with all that, no one should be allowed to cover their arses as it turns into a vicious circle of unaccountability. It's a poor excuse which must not be allowed to continue in the profession (or ANY profession to be honest).
jon-wood 12y ago
I think this sort of process is slowly filtering into the NHS. As a piece of anecdata, my wife had an incredibly long and difficult labour when giving birth to our son. Afterwards we were referred to what our local hospital calls a birth reflection service, where you sit down with a trained midwife, and run through all the notes and talk over what happened. Whilst the primary purpose was to help us piece together everything that had happened[1] and process that there definitely seemed to be an element of the midwife going through things taking down notes on places where things had gone wrong for later follow up. [1] After five days of labour, including three extended trips back and forth to the hospital, it got a bit difficult to even work out on what day things happened, never mind what order they happened in.

paulhauggis 12y ago

"Most medical professionals are competent and skilled, and really try rather hard to avoid causing harm to their patients. But mistakes and accidents will always happen regardless of this." I don't know if I believe this. I have found many medical professionals (not all of course) to be arrogant and cocky and even if you pointed directly to the cause of the problem, would most likely not think that those rules apply to them. "not on who is responsible for them" Mistakes happen because of people. If there isn't some sort of punishment or blame, the majority of people will just continue on with what they are doing (and the mistakes will continue to happen). We need to blame people, so they change their behavior and have less accidents in the future. We also need to know why it happened. "Blame is almost poisonous in its ability to encourage people to cover up the truth" If someone covers up the truth, they should be fired immediately. I honestly don't want someone like this working anywhere near the medical field..and neither should you. Children cover up their mistakes and lie..adults own up to their problems and admit when they made a mistake. Also, the reason pilots have less mistakes is because a computer pretty much does 99% of the work. This is not the case with surgery and medicine. Humans still do most of the work.

ISL 12y ago
Mistakes happen because of people's errors, not 'because of people'. To blame a person, rather than their actions, is to alienate them. You want everyone on your team to be focused on quality outcomes, not on avoiding blame.
- pling 12y ago
  The NHS currently runs on avoiding blame which is the problem. When someone is made accountable and the first thing they do is establish a process to avoid blame then you need to ask the question: do these people have my best interests at heart or are they avoiding being accountable? On many occasions the outcome is to avoid a breach rather than to fix a problem.
  - ZoFreX 12y ago
    The NHS also runs on overworking its employees and assuming they will still be effective at the end of a 20 hour shift with no sleep. If anyone making a completely understandable mistake due to the terrible conditions they have to work in is blamed and fired for it, would that really help? I think it's understandable for people to cover their own ass if they are expected to be infallible even under poor conditions - everyone else is doing it, if you don't the only difference it makes to the NHS is that it's down one employee. This is just one way of many possible ways that what might first appear to be a single human failing is down to a larger institutional problem.
    - pling 12y ago
      No they don't. That's the nursing unions and the press talking. It's total bollocks. The decision makers and the senior staff have considerably smaller shifts. With respect to the surgical and anaesthesiologist staffing, most of them (80%+) are contracted out and are private staff working on contract to the NHS now. A surgeon for example will probably spend two days a week on NHS cases, one day being surgical and the other being consultant and that's all you see of them. The remainder of the time is lucrative private care and occasionally teaching (which is well paid as well). There are a few exceptions to this i.e. StR's and consultants who seem to migrate into a speciality then leave after a few years. They all take the extra shifts because they're paid for the privilege of up to a 50% bonus. They're overworked because they're chasing the cash. The REAL overworked staff are mainly the support staff i.e nursing, supply, logistics. Most of them are contracted out now as well in the larger PCTs. Even with all that, no one should be allowed to cover their arses as it turns into a vicious circle of unaccountability. It's a poor excuse which must not be allowed to continue in the profession (or ANY profession to be honest).

jon-wood 12y ago

I think this sort of process is slowly filtering into the NHS. As a piece of anecdata, my wife had an incredibly long and difficult labour when giving birth to our son. Afterwards we were referred to what our local hospital calls a birth reflection service, where you sit down with a trained midwife, and run through all the notes and talk over what happened. Whilst the primary purpose was to help us piece together everything that had happened[1] and process that there definitely seemed to be an element of the midwife going through things taking down notes on places where things had gone wrong for later follow up. [1] After five days of labour, including three extended trips back and forth to the hospital, it got a bit difficult to even work out on what day things happened, never mind what order they happened in.