| Not sure if anyone has been following but this is utterly heartbreaking on 09:30 - Aug 14 with 878 views | Herbivore |
Thanks for sharing that, really interesting if up setting reading. Blame culture ultimately doesn't help anyone and generally tends to make future errors more likely rather than less likely and it does seem like the doctor was thrown under the bus for admitting where she'd made mistakes. The consultant doesn't come out of it at all well for me. Really tragic for the family, although difficult to say conclusively whether he would have survived with earlier treatment as it seems the sepsis had really taken hold of the poor little boy. |  |
|  |
| Not sure if anyone has been following but this is utterly heartbreaking on 09:32 - Aug 14 with 870 views | itfcjoe |
| Not sure if anyone has been following but this is utterly heartbreaking on 09:30 - Aug 14 by Herbivore |
Thanks for sharing that, really interesting if up setting reading. Blame culture ultimately doesn't help anyone and generally tends to make future errors more likely rather than less likely and it does seem like the doctor was thrown under the bus for admitting where she'd made mistakes. The consultant doesn't come out of it at all well for me. Really tragic for the family, although difficult to say conclusively whether he would have survived with earlier treatment as it seems the sepsis had really taken hold of the poor little boy. |
Have you read Black Box Thinking by Matthew Syed?
Really interesting with regards to how msitakes are handled in industry with the 2 biggest differences between Airline (learning tools to improve) and Healthcare (Swept under rug, denied and denied) |  |
| |
| Not sure if anyone has been following but this is utterly heartbreaking on 09:44 - Aug 14 with 822 views | solemio |
| Not sure if anyone has been following but this is utterly heartbreaking on 09:32 - Aug 14 by itfcjoe |
Have you read Black Box Thinking by Matthew Syed?
Really interesting with regards to how msitakes are handled in industry with the 2 biggest differences between Airline (learning tools to improve) and Healthcare (Swept under rug, denied and denied) |
That's very interesting, Joe, and certainly true as a generalisation. People have died on the operating table because nobody dared to tell the almighty consultant surgeon that they had noticed something wrong.
Martin Elliott, heart consultant at Great Ormond Street, however, has been to airlines and to Ferrari at Modena to learn from them. He realised when watching F1 wheelchanges that everyone knew their job and that medical people could learn from them. Also there was no fear of speaking out.
He is an internationally respected person and these ideas are spreading.
However this does not help the under-funding and under-staffing. |  | | |
| Not sure if anyone has been following but this is utterly heartbreaking on 09:54 - Aug 14 with 793 views | Herbivore |
| Not sure if anyone has been following but this is utterly heartbreaking on 09:32 - Aug 14 by itfcjoe |
Have you read Black Box Thinking by Matthew Syed?
Really interesting with regards to how msitakes are handled in industry with the 2 biggest differences between Airline (learning tools to improve) and Healthcare (Swept under rug, denied and denied) |
I've read some stuff by James Reason which is more 'academic' but along similar lines. Interestingly airlines, which Reason also focused on, used to be obsessed by pilot error and measures introduced to eradicate error had no positive impact on accidents happening. They moved towards a more systemic approach to understanding the conditions in which errors happen and this helped hugely. In the public services, including the NHS, that has never really happened. There is still much more focus on blame than there is on learning which makes it hard to acknowledge errors and to then meaningfully learn from them. | |
| |
| |
By continuing to use the site, you agree to our use of cookies and to abide by our Terms and Conditions.
