Without an accountable "system" where roles & responsibilities are defined as part of a quality system I'm not sure we can break free of the cycle. When I see a "whistle blower" I see someone who actually did their job. Perhaps social action from patients/public would help.
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Replying to @DanielBayley80 @CarrieMaisie and
Daniel you're selling aviation as the perfect organisation yet we all know they aren't. The level of employee error accidents in your industry is well documented, from drunken pilots to poor quality maintenance. The reason we know is because staff come forward after the event.
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Replying to @Testing_1212 @CarrieMaisie and
I'm selling aviation as something which came from a very worrying place to 1 of the safest. It is not perfect by any stretch, but the journey they went on, the systems, processes, etc they put in place have had a huge impact. Healthcare lags some 10-20 years behind this journey.
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Replying to @DanielBayley80 @Testing_1212 and
And the important point you make is about staff coming forward. the willingness to investigate and learn. the spread of those lessons throughout the industry. They try to avoid the same mistakes. The NHS fails to learn lessons locally nevermind nationally.
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Replying to @DanielBayley80 @CarrieMaisie and
As does aviation that leads to the death of innocent people just like the NHS
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Replying to @Testing_1212 @CarrieMaisie and
Follow the path of an air crash investigation. they seek to design the risks out the system post event. the NHS just dusts itself off and caries doing the same. There just isn't the same culture of continuous quality improvement.
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Replying to @DanielBayley80 @Testing_1212 and
Killing paying passengers would bring down the airline industry. Killing patients will never bringdown the health system.
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Replying to @AdrienneCullen @DanielBayley80 and
There is an inevitable baseline mortality rate ie 100% of everyone dies. We are trying to identify the deaths which are preventable or premature versus one that is expected. This is not always easy when the patient is already unwell or frail. How do we benchmark this?
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Replying to @dymonite69 @DanielBayley80 and
Beyond my paygrade. But it's probably a good idea to document/count individual deaths directly attributable to error instead of just extrapolating figures. We have a WHO figure of 95,000 avoidable deaths per anum in the EU. I don't know how many harmed. Worry about them first?
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Replying to @AdrienneCullen @DanielBayley80 and
I am always curious how avoidable deaths are identified. It usually requires a detailed root cause analysis. I suspect most figures relate to some form of extrapolation set by benchmarks on another population. External validity?
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There's only one person to turn to for questions of this sort - @Jarmann is your man.
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Replying to @C7RKY @dymonite69 and
Illness Care is now highly complex high risk teamwork Our information systems are incapable of supporting this type of work at the speed and safety required. All patients suffer substandard care whether Good Outcomes or ‘Avoidable’ Deaths
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