ZHH Alison, I’m afraid you’re on a completely different track. Zero Avoidable Deaths + Zero Avoidable Harm are not a dream, they are part of the Critical Moral Imperative of healthcare delivery. The acceptance of avoidability is a fundamental part of #patientsafety
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Yes they are, Ken. And there is more than sufficient evidence to say so. As well as evidence (and ongoing problems) that over-standardising reduces system resilience and individual ability to adapt to the real variation that is inherent in human health and illness.
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ZHH Are you still saying Zero Avoidable Deaths + Zero Avoidable Harm are a dream?
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Yes Ken - an important aspiration or vision - of the Martin Luther King variety
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ZHH Dreadfully disturbing attitudes! So what about the victims of the Avoidable Deaths + Avoidable Harm? What about their loved ones? I’m horrified!
@doctorcaldwell@TheDA_UK@C7RKY@ObsGynKenobi1 reply 0 retweets 0 likes -
Replying to @KenZeroHarm @AlisonSJones5 and
Not disturbing at all. The term ‘avoidable’ is horrendously subjective, prone to misinterpretation and is inherently judgemental of past episodes from the perspective of the ‘Retrospectoscope’.
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Replying to @Cjw450Cathy @AlisonSJones5 and
ZHH You’re not familiar with the Structured Judgement Review?
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Replying to @KenZeroHarm @AlisonSJones5 and
More judgement made on ‘restrospective knowledge’, another tool to point fingers whilst missing deeper systemic issues. These reviews have a place, but have very limited value akone without balancing in-depth understanding of how work really done at time of events.
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Replying to @Cjw450Cathy @AlisonSJones5 and
ZHH Sorry, Cathy, but I really understand none of this stuff; are you criticising the Structured Judgement Tool? In Mortality+Morbidity Reviews you never judge any Death Avoidable?
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Replying to @KenZeroHarm @Cjw450Cathy and
I’ve looked at over 400 deaths under my care without believing one of them was Avoidable. I’ve seen plenty of weaknesses & errors and passed on all the ones I’ve worried about for investigation. After investigators have looked none were judged Avoidable...
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You said elsewhere that you hadn't acquired a definition of an 'avoidable death' from anyone, so what definition did the investigators use when they made their determinations here?
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