Lilly lecture 2013
Professor Berwick opened up with a personal example of how, as a junior doctor, he found that systems present in hospital can be confusing, especially when procedures vary from those in nearby hospitals, which can lead to make fatal mistakes being made and that, aside from personal examples, it is known that genuine mistakes happen regularly.
Questions were asked and then discussed:
- How do doctors deal with recognising the harm that was caused by genuine individual mistakes, or by a misunderstanding between professionals, or by not being familiar with the procedures?
- How many doctors follow up their mistakes?
- How many doctors raise the failure (system or individual) with the authorities, or those senior to them?
Professor Berwick went on to say that human factors that contribute to safety, or conversely accidents, are real and predictable. This was demonstrated by using handwriting as an example – real examples taken from medical records, that demonstrated how the written word could be interpreted in a variety of ways in a healthcare environment.
Professor Berwick went on to say that he believes that the science of safety is crucial to driving up quality standards in patient care, not just the science of treatment and that the mantra ‘every patient is the only patient’ should be our mantra when it comes to safety. 'Injury and death produced by medical interventions or accidents in the US are greater than those of road traffic accidents, workplace and aeroplane accidents'.