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 @AdrienneCullen and
Most Unavoidable Deaths should be Anticipated and provision made for Calm End of Life. So maybe more rewarding to investigate Unanticipated Deaths & those with poor End of Life Care?
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Replying to @doctorcaldwell @dymonite69 and
On a first read, this made sense. But as I pondered, I couldn't help but be reminded of the gaming of stats that went on at Mid Staffs. I'm always v nervous about who gets to decide what is an avoidable/unavoidable death & what is 'anticipated'. Needs regular scrutiny there too.
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Replying to @C7RKY @dymonite69 and
Good point. I believe we should audit in detail say 1 in 10 sets of notes of patients who spent at least 5 days as inpatient whether discharged alive or dead and the ‘auditor& should be blind to the outcome. Data should then be reported by Care Team.
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Replying to @doctorcaldwell @C7RKY and
But the Big Message would still be the same - paper handwritten notes prescription & Clinical monitoring processes and without watertight order Comms are a major daily risk to
#PatientSafety harming those who ‘survive’ and those who die - avoidable or nothttps://www.dropbox.com/s/1p1g0dgxymwea9h/KingsFundMay2017.pdf?dl=0 …1 reply 0 retweets 2 likes
I don't think you've ever had resistance from me on this one? And I'm not about to start now. Everything about paper-only systems is unfit for purpose in a modern world, with one exception - cover ups. Paper records are really helpful for those with designs on covering things up.
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Replying to @C7RKY @doctorcaldwell and
Yes - especially when paper records are not backed up electronically
#Gloucestershire - quite extraordinary in this day & age0 replies 0 retweets 0 likesThanks. Twitter will use this to make your timeline better. UndoUndo
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