Reporting on patient safety and medical errors

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Reporting on patient safety and medical errors

• Richard Smith
• Editor, BMJ
• www.bmj.com/talks

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What I want to talk about

• A picture
• A story
• Why did we forget?
• The report
• The role of medical journals
• The role of the mass media
• The role of the web
• The role of the WMA

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A picture
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A story
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Theres nothing new about this

• First, do no harm

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Why then did we forget it?

• We didnt understand the extent of the harm
• We were too busy concentrating on benefit
• Its painful to think about harm
• There but for the grace of God go I
• We thought about it in terms of culpability and
  didnt know how to respond

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The report Institute of Medicine Report

• To Err is Human Building a Safer Health System
• Put safety to the top of the US health agenda
• Every country needs one

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The role of medical journals
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What journals cant do

• Make change happen straight away Words on paper
  dont change things
• Tell people what to think

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What journals can do

• Disturb, stir up, encourage debate
• Set agendas Tell people what to think about
• Legitimise If the NEJM is talking about safety
  it must be important

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The role of medical journals

• Reporting scientific data
• how many errors?
• what type?
• why do they happen?
• what should be done about them?
• Raising consciousness
• Setting the agenda
• Educating

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Reporting error USA

• Harvard Medical Practice Study
• Published in the New England Journal of Medicine
  in 1991
• In 3.7 of hospital admissions an adverse event
  led to harm

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Reporting error Australia

• Australian study
• Published in the Medical Journal of Australia in
  1995
• An adverse event occurred in 16.6 of admissions

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Not reporting error UK

• If the US results apply in then about 45 000
  may die in part because of the adverse
  eventEvery country needs such a study
• BMJ editorial, 1990

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Violet Vanbrugh
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Setting the agendaRaising consciousnessEducati
ng

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How to reduce error

• Quality improvement reports
• Context
• Problem
• Measures of improvement
• Information gathering
• Strategy for change
• Effects of change
• Next steps

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Journals specifically concerned with safety
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The role of the mass media

• Reporting cases to the world the world is
  interested
• Reporting data
• Explaining error Why does it happen? What can be
  done?
• Generating political commitment for improvement

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The role of the web

• Enormous potential for sharing
• High quality information
• Tools
• Experiences
• Contacts
• Many websites are appearing and will appear

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Purpose of Qualityhealthcare.org

• Help improve the quality of health care worldwide
• Be easily accessible free or at very low cost
• Provide trusted content and tools to improve
  healthcare
• Put experts throughout the world in touch with
  one another

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The role of the WMA

• Raise consciousness
• Convince member associations that they should be
  thinking about this issue and doing something
• Put them in touch with people who can help them
• Produce a grand statement that commits members to
  improving patient safety