Posted by: Maureen O'Sullivan22 MAR 2013
Patient safety activist Sorrel King stole the show at the European Association of Hospital Pharmacists annual congress and she wasn’t even there. Sorrel King is not a patient safety expert. She’s not a pharmacist, a nurse or a doctor. No, Sorrel King is not a healthcare professional at all. She is the mother of a child who died at the hands of healthcare.
Professor Norbert Pateisky is a patient safety expert. Last week I attended his keynote presentation at the closing ceremony of the 18th congress of the EAHP during which he showed a speech that Sorrel King made to health professionals about patient safety 10 years ago.
Branding hospitals “man-made epidemics” and appealing to health professions not for their pity but for their help, Mrs King’s emotional address captivated the audience of hospital pharmacists I sat amongst as it did the audience of doctors and nurses she spoke to a decade earlier.
Josie King died as a result of medical errors. Her mother described her death as a consequence of a breakdown in the entire medical system that was trying to help her. The story of her death — and those of so many like her — is a stark reminder of the devastating consequences of human error.
You may think you’ve read about patient safety before, and you have countless times. Yet, medical errors still occur and people are still dying because of them. As Mrs King points out, unlike for cancer or HIV, a scientific breakthrough will not fix these problems. To do so, all healthcare professionals need to think about patient safety every day, they need to apply it to everything they do and they need to do it together.
There is some fantastic work going on around the world to improve patient safety. Professor Patiesky is collaborating with aviation safety experts in Austria to determine how their approach to flight safety can be applied to medical safety. The Josie King Foundation funds patient safety initiatives all over the US and is dedicated in its mission to create a culture of patient safety.
Closer to home, the Scottish Patient Safety Programme was launched in Scottish hospitals five years ago and has recently revealed a drop in hospital death rates. Its roll-out to primary care was kicked off last week and is already attracting worldwide attention.
Incidentally, in the lead up to the official day 1 of the NHS reforms in England (April 1) we should be reflecting on the demise of the National Patient Safety Agency and hope that its safety functions — transferred to the NHS Commissioning Board — remain relevant and potent.
The common threads running through good patient safety initiatives, and which formed the basis of Professor Patiesky’s thought-provoking presentation, are communication, teamwork, respect and support. Without these, then there is no procedure, standard or expertise in the world that can guarantee that patients are safe. With them, I think we might just be able to conquer this man-made epidemic.
The 18th congress of EAHP was held in Paris on 13–15 March 2013.