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C7RKY's profile
John Clarke
John Clarke
John Clarke
@C7RKY

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John Clarke

@C7RKY

Of course views all mine. All without prejudice. Just a regular chap after all. Oh...and RT's may equally imply ridicule as endorsement.

UK
Joined December 2011

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    1. Daniel Bayley‏ @DanielBayley80 Oct 13
      Replying to @CarrieMaisie @Testing_1212 and

      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.

      2 replies 0 retweets 6 likes
    2. Marcus‏ @Testing_1212 Oct 13
      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.

      2 replies 0 retweets 3 likes
    3. Daniel Bayley‏ @DanielBayley80 Oct 13
      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.

      3 replies 0 retweets 5 likes
    4. Daniel Bayley‏ @DanielBayley80 Oct 13
      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.

      3 replies 5 retweets 9 likes
    5. Marcus‏ @Testing_1212 Oct 13
      Replying to @DanielBayley80 @CarrieMaisie and

      As does aviation that leads to the death of innocent people just like the NHS

      1 reply 0 retweets 2 likes
    6. Daniel Bayley‏ @DanielBayley80 Oct 13
      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.

      4 replies 10 retweets 10 likes
    7. DocXology‏ @dymonite69 Oct 14
      Replying to @DanielBayley80 @Testing_1212 and

      That’s because the teams that investigate crashes actually understand the industry and the system. You’ve got the GMC or a lay jury.

      1 reply 0 retweets 5 likes
    8. John Clarke‏ @C7RKY Oct 16
      Replying to @dymonite69 @DanielBayley80 and

      Both of whom inform their opinion through the use of 'expert' witnesses who should have investigated the evidence though, no? We could add a lot more organisations to that list. NHSE, CQC, NMC, Monitor etc. There are many cooks with their hand in this particularly toxic broth.

      4 replies 2 retweets 6 likes
    9. Dr Gordon Caldwell‏ @doctorcaldwell Oct 16
      Replying to @C7RKY @dymonite69 and

      I am working on a Structured Death Review - the notes are 20cm thick & weigh about 4Kg. It takes so much time to locate the information let alone understand it, yet we stick with this process that makes Care slow and dangerous

      1 reply 1 retweet 2 likes
    10. Dr Gordon Caldwell‏ @doctorcaldwell Oct 16
      Replying to @doctorcaldwell @C7RKY and

      The current clinical notes paper or computer contain too much information and not enough synthesis & wisdom. Also no connection digitally between GP & Hospital or GP to GP nor Hospital to Hospital nor England to Scotland or Wales or NI and definitely not with the patient

      2 replies 2 retweets 3 likes
      John Clarke‏ @C7RKY Oct 16
      Replying to @doctorcaldwell @dymonite69 and

      It's a separate point to the expert witness one where we started, but is there no 'dashboard' at all? Even business has worked out you need the key data on the front page of any report/file, preferably with RAG indicators (Red/Amber/Green) to draw the eye where questions beg.

      1:47 AM - 16 Oct 2018
      • 1 Retweet
      • Ken Lownds
      1 reply 1 retweet 0 likes
        1. New conversation
        2. Dr Gordon Caldwell‏ @doctorcaldwell Oct 16
          Replying to @C7RKY @dymonite69 and

          When I do Structured Death Review the starter questions are Date Day Time admitted? This can take 15minutes trawling various notes and systems to discover we don’t know for sure. That’s how unusable our information and systems are ..

          1 reply 0 retweets 2 likes
        3. Dr Gordon Caldwell‏ @doctorcaldwell Oct 16
          Replying to @doctorcaldwell @C7RKY and

          For The current death review I am doing I could find the time patient clerked but not the arrival time in Hospital after transfer from another NHS Hospital with no transfer letter. I then had to look up in a calendar which day of the week that was ...

          2 replies 1 retweet 4 likes
        4. Dr Gordon Caldwell‏ @doctorcaldwell Oct 16
          Replying to @doctorcaldwell @C7RKY and

          Presumably I am meant to be looking for possible failures leading to a possibly Avoidable Death but actually spend huge amounts of time working out dates & times. Generally no information about seniority of Doctor Doing the Daily Review. Usually no Problems List #LarryWeed

          1 reply 3 retweets 3 likes
        5. Dr Gordon Caldwell‏ @doctorcaldwell Oct 16
          Replying to @doctorcaldwell @C7RKY and

          So the NHS does not prospectively collect information in usable formats to establish timelines - timeline is vital for Diagnosis & refining Clinical Management, so no surprises to me when it goes wrong. The time taken to Review Notes proves the notes are not fit for purpose

          1 reply 3 retweets 5 likes
        6. 1 more reply

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