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Reporting on patient safety and medical errors. Richard Smith Editor, BMJ www.bmj.com/talks. 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. A picture.

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reporting on patient safety and medical errors

Reporting on patient safety and medical errors

Richard Smith

Editor, BMJ

www.bmj.com/talks

what i want to talk about
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
there s nothing new about this
There’s nothing new about this
  • “First, do no harm”
why then did we forget it
Why then did we forget it?
  • We didn’t understand the extent of the harm
  • We were too busy concentrating on benefit
  • It’s painful to think about harm
  • “There but for the grace of God go I”
  • We thought about it in terms of culpability and didn’t know how to respond
the report institute of medicine report
“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
what journals can t do
What journals can’t do
  • Make change happen straight away: “Words on paper don’t change things”
  • Tell people what to think
what journals can do
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”
the role of medical journals11
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
reporting error usa
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
reporting error australia
Reporting error: Australia
  • Australian study
  • Published in the Medical Journal of Australia in 1995
  • An adverse event occurred in 16.6% of admissions
not reporting error uk
Not reporting error: UK
  • “If the [US] results apply in then about …45 000 may die in part because of the [adverse] event…Every country needs such a study…”
  • BMJ editorial, 1990
slide15

Violet

Vanbrugh

how to reduce error
How to reduce error
  • Quality improvement reports
  • Context
  • Problem
  • Measures of improvement
  • Information gathering
  • Strategy for change
  • Effects of change
  • Next steps
the role of the mass media
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
the role of the web
The role of the web
  • Enormous potential for sharing
  • High quality information
  • Tools
  • Experiences
  • Contacts
  • Many websites are appearing and will appear
purpose of qualityhealthcare org
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
the role of the wma
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