Reporting on patient safety and medical

errors

Richard SmithEditor, BMJ

www.bmj.com/talks

What I want to talk about

• A picture• A story• Why did we forget?• “The report”• The role of medical journals• The role of the mass media• The role of the web• The role of the WMA

A picture

A story

There’s nothing new about this

•“First, do no harm”

Why then did we forget it?

• We didn’t understand the extent of the harm

• We were too busy concentrating on benefit• It’s painful to think about harm• “There but for the grace of God go I”• We thought about it in terms of culpability

and didn’t know how to respond

“The report”: Institute of Medicine Report

• To Err is Human: Building a Safer Health System

• Put safety to the top of the US health agenda

• Every country needs one

The role of medical journals

What journals can’t do

•Make change happen straight away: “Words on paper don’t change things”

•Tell people what to think

What journals can do

• Disturb, stir up, encourage debate• Set agendas: “Tell people what to

think about”• Legitimise: “If the NEJM is talking

about safety it must be important”

The role of medical journals

• Reporting scientific data– how many errors?– what type?– why do they happen?– what should be done about them?

• Raising consciousness• Setting the agenda• Educating

Reporting error: USA

• Harvard Medical Practice Study

• Published in the New England Journal of Medicine in 1991

• In 3.7% of hospital admissions an adverse event led to harm

Reporting error: Australia

• Australian study

• Published in the Medical Journal of Australia in 1995

• An adverse event occurred in 16.6% of admissions

Not reporting error: UK

• “If the [US] results apply in then about …45 000 may die in part because of the [adverse] event…Every country needs such a study…”

• BMJ editorial, 1990

Violet Vanbrugh

Setting the agenda

Raising consciousness

Educating

How to reduce error

• Quality improvement reports• Context• Problem• Measures of improvement• Information gathering• Strategy for change• Effects of change• Next steps

Journals specifically concerned with safety

The role of the mass media

• Reporting cases to the world: the world is interested

• Reporting data• Explaining error: Why does it

happen? What can be done?• Generating political commitment

for improvement

The role of the web

• Enormous potential for sharing• High quality information• Tools• Experiences• Contacts• Many websites are appearing and will

appear

Purpose of Qualityhealthcare.org

• Help improve the quality of health care worldwide

• Be easily accessible free or at very low cost

• Provide trusted content and tools to improve healthcare

• Put experts throughout the world in touch with one another

The role of the WMA

• Raise consciousness• Convince member associations that

they should be thinking about this issue and doing something

• Put them in touch with people who can help them

• Produce a grand statement that commits members to improving patient safety