Patientsäkerhet

Det pågår en del arbete inom arbetet i den brittiska motsvarigheten till landsting, NHS, för att förbättra och komma åt problemen med dålig säkerhet inom vården. Det brittiska systemet är kanske det som liknar det svenska mest och det finns flera paralleller som kan dras. Tyvärr kanske mest på det negativa planet. Följande kommentar gör Dr John Ray i Brisbane på sin blog:

Yet last month, the Chief Medical Officer, Sir Liam Donaldson, warned that the odds of dying as a result of clinical error in hospital are 33,000 times higher than those of dying in an air crash. ”In the airline industry, the risk of death is one in 10 million. If you go into a hospital, the risk of death from a medical error is one in 300,” he said. And yet it seems little is being done to improve those odds. Five years after chairing the inquiry into the deaths of 29 babies during heart surgery at Bristol Royal Infirmary, Sir Ian Kennedy, now chairman of the Health Commission, drew attention to the lack of progress. ”It is almost as though avoidable deaths and injuries are accepted as part of the risk of care and treatment,” he told a meeting of clinicians in London in July.

And it gets worse: the National Patient Safety Agency (NPSA), which was set up by the Government in response to the Bristol inquiry, with a brief to ensure that patient safety was a priority within the NHS, was recently described as ”dysfunctional” by the National Audit Office. The agency has no idea how many people die each year as a result of medical error. It is currently under investigation, with a report on its future due out this week. The National Audit Office estimates that there may be up to 34,000 deaths annually as a result of patient safety incidents. But in reality the NHS simply does not know.

Contrast this with the approach taken by other high-risk industries. For years, businesses from motor racing to oil refining have recognised the dangers of human error, and the importance of communication and teamwork in dealing with emergencies. They have introduced what is known as Human Factors (HF) training, which teaches basic skills designed to promote safety. While much-prized technical skills are essential, they are not always enough in a fast-moving, high-risk situation. At critical moments, organisational and social skills are just as important. This means good communication and an ability to work together with each member of the team.

Ett helt relevant resonemang även för den svenska vården. Det händer saker, varje dag, men vi vet faktiskt inte hur mycket, hur ofta eller varför. I en så pass känslig och högkompetent verksamhet borde patienterna kunna ställa högre krav.