The Antidote

Counterspin for Health Care and Health News

Sunday, February 21, 2010

I hate it when health care kills people...

...which is why I'm happy when the media do a good job of covering this underappreciated issue. BBC Radio 4 just broadcast an excellent piece on patient safety in the UK. It focuses on alerts issued by the National Patient Safety Agency to local NHS trusts. The alerts are based in part on aggregated reports of errors - or, as some in the US call them, adverse events, to avoid the language of blame - and are meant to help trusts, which have primary responsibility for delivering safe health care, to implement specific procedures aimed at avoiding errors. Trusts are responsible for reporting back on their progress implementing the alerts; there are, evidently, hundreds of trusts that have not yet implemented at least one, and there are a couple more that have not reported back on over 30. A key problem is that there is no national mechanism or authority for enforcing compliance with the alerts, although they are issued at the national level.

The story, about 40 minutes long, did an excellent job of interweaving anecdotes with investigative reporting on NHS policies and procedures. The reporter, Julian O'Halloran, spoke with patients' family members who have now become active in improving patient safety in the UK, as well as policymakers.

One case highlighted was that of a man who was killed by a massive overdose of a painkiller. The media have focused heavily on the fact that the doctor who administered the drug was foreign and had apparently been censured by medical authorities in his home country, that he was unfamiliar with the drug in question, diamorphine, and also that the incident occurred on his first shift working in the UK. What the media have not grasped - until now - was that the drug ampule the doctor used should probably never have been in his medical kit to begin with, because such a high dose has almost no application in day-to-day use. The NPSA had issued guidance in 2006 about safe storage practices for diamorphine, to help clinicians avoid administration errors. O'Halloran spoke to the patient's son, who is himself a doctor, and who mentioned that he had never even seen such a large dose of diamorphine.

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