21 September 2008

Why do managers ignore patient safety?

Last week Dr Grumble saw a patient whom he thought he recognised. She seemed familiar. He thought he must have seen her before. So he checked the records to be sure. But there was nothing. Dr Grumble is getting on. From time to time he is mistaken. But then he asked the patient what her occupation was. She described herself as a Bought Ledger Clerk. Dr Grumble then remembered that the patient that he recalled also described herself as a Bought Ledger Clerk. What a coincidence. But it was not, of course, a coincidence. The patient had been registered twice, had two sets of records and had been referred twice to Dr Grumble for the same problem and had managed to get two new patient appointments within a week of each other. It happens all the time. It's embarrassing. Worse - it's dangerous. Dr Grumble apologised for his confusion and the patient told him that she had repeatedly been telling hospital staff that she had been double registered. Not one of the hospital staff she told took any action. This makes Dr Grumble angry. He arranged to have the problem put right. It is such an important problem that Dr G would do this task himself. But he is not allowed to.

This problem has been making Dr G angry for years. Two years ago he decided to have a blitz on the problem with the newly introduced online clinical incident reporting system. On average twice a week for several months Dr Grumble dutifully sent in reports on patient identification problems. Nobody took much notice. Eventually, after an exchange of emails Dr Grumble asked if he was wasting his time reporting these problems. Was there any point? And eventually he was told that he might as well not bother because they were doing all they could. That made Dr Grumble even more angry.

But Dr Grumble has an acquaintance in high places. And this is what he says on the topic:

We should no longer accept the level of misallocated records and the misidentification of patients as inevitable or normal.

Thanks for listening Bruce. And thanks for dealing with a longstanding problem that could have been solved long ago.

Dr Grumble's hospital now has a doctor as a Chief Executive. He is much better than the previous incumbent. So perhaps he will do something about this problem. We shall see.

1 comment:

Betty M said...

Pity Bruce couldn't manage to improve things at his own hospital where yet again I attended an appt last week and my notes were awol and the 3rd set of shadow notes this year were started.