The Medical Defence Union is calling on healthcare leaders to ensure a just culture within their workplace to ensure doctors are not unfairly singled out for blame when things go wrong.
In a blog on the MDU’s website, ahead of the first annual World Patient Safety Day, which takes place on Tuesday 17th September, Dr Michael Devlin calls for lessons to be learned from mistakes of the past.
Dr Devlin, MDU head of professional standards, explained:
“In order to move forward with improving patient safety, it’s important to acknowledge that the punitive systems of old have not served patients and their families well. However, a fresh approach, built on a just culture, will.
“The current system is almost set up to fail; a patient's unexpected and preventable death may lead to a criminal investigation, a coronial investigation, disciplinary and regulatory procedures, civil litigation and media coverage. Sometimes these processes are necessary, but where the focus almost immediately narrows to an individual's failings, what is often lost is the opportunity to properly and rigorously examine the context and the wider systems failures that are often at the heart of such incidents.
“We saw this following the tragic and avoidable deaths associated with accidental intrathecal injection of vincristine prior to 2000. For decades, doctors were criminalised for their part in fatal drug administration errors, but this did not help. What was ultimately needed was to understand the human and systemic factors that influenced their behaviours.
“We know that the move to a just and learning culture will not happen overnight. It will require knowledgeable and motivated clinical leaders and managers, and time to restore trust and confidence in processes designed to investigate clinical errors. However there is already some useful guidance out there which leaders can turn to such as NHS Resolution's report Being Fair and NHS Improvement's Just culture guide.
Picture of Dr Michael Devlin attached.
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