Morning DJ. As a medical expert witness in clinical negligence cases I’d like to discuss this with you. I understand the message you’re trying to get across but it doesn’t quite work, with a notable reason being you’re mixing statistics with different definitions, numerators and denominators, and presenting them as if they’re comparable, which they’re not.
There’s an important difference between an airline pilot or healthcare worker making a mistake and the premeditated intent - malfeasance, as you put it - of deliberately killing people under their charge. A more appropriate comparison would be between Letby and the pilot of the flight who locked his Co-pilot out of and flight deck and crashed his aircraft into the sea.
When a pilot decides to crash, the result is pretty much always mass death, but in healthcare there are frequently only short periods of time when the bad actor is alone in which they can harm their patient, and the harm is often not fatal, as we saw with Letby.
Letby won’t be the last healthcare mass murderer, and I expect we will see another murdering pilot. They just change their MO. Systems learn from mistakes.
And you mention a statistic comparing the risk of dying on a flight with the risk of suffering an adverse event. They’re clearly not the same. Most AES and non-intentional and only a tiny fraction are fatal. And yes I’m aware of the “two jumbo jets a day” headline, but that again is eye catching but misleading.
I agree that the "two jumbo jets" statistic is probably plain wrong, which is why I didn't quote it. The original 2-13 paper that put the number of deaths from medical error at 300-400k in the US has, I think, been largely debunked.
And of course I realise that adverse events in healthcare and deaths from air accidents are not the same thing. The comparison serves only to highlight the enormous gulf that exists between healthcare and the airline industry in terms of safety. The comparison may not be fair, given the variability in healthcare that cannot be eliminated as it can be in flying.
That said, there is no equivalent organisation to the ICAO in healthcare. If you fly into any airport in the world, the whole affair is standardised - from the letter sizing of signs, right down to the height of the grass. Every hospital, even every ward, works in a completely different way.
It is also interesting to realise - especially as evidenced in Matthew Syed's book - how little healthcare institutions are set-up to learn from each other.
While in general agreement with the point you are making (in a nutshell, that the blame culture is bad for patients safety and the inevitability of hindsight) I consider it a gross understatement to say “imagine one consultant drops in your office one day and states there is a nurse who is a serial killer”. This is not what happened. What happened was that 7 consultant pediatricians were expressing concerns over a prolonged period of time based on nursing shifts patterns, increased mortality rates and clinical incidents which were identified as sudden and unexpected. The way they were bullied by managers, as evidenced by emails shown on BBC, was disgraceful. If we are to promote a speak up, blame free culture, we need to ensure that those who speak up are listened to. Letby was eventually assigned to non clinical duties and the mysterious incidents ceased. Police, however, was not called for many more months. The concerned consultants could also have gone to the police themselves, like any private citizen would do if they strongly suspect criminal activities around them. Attention to systems doesn’t mean that personal accountability should not exist.
Thanks for sharing your thoughts. I haven't seen the emails that you speak of - although I have no doubt that the managers and the clinicians were in contention for a long time over this issue. We have all written emails that we wish we could 'unsend'. Thankfully none of mine have been scrutinised in the harsh light of national media.
And in fact my point here is that what was missing was both the culture and the systems to protect these vulnerable patients. The managers may have made mistakes, but we are not going to prevent future harm by chasing them down and punishing them.
The good news is that the new Medical Examiner role in hospitals may improve the independence of investigation earlier in the process, albeit within the same hospital. It's not much, but it's an example of the changes that could be made that will have an impact long after everyone has forgotten this tragedy.
Morning DJ. As a medical expert witness in clinical negligence cases I’d like to discuss this with you. I understand the message you’re trying to get across but it doesn’t quite work, with a notable reason being you’re mixing statistics with different definitions, numerators and denominators, and presenting them as if they’re comparable, which they’re not.
There’s an important difference between an airline pilot or healthcare worker making a mistake and the premeditated intent - malfeasance, as you put it - of deliberately killing people under their charge. A more appropriate comparison would be between Letby and the pilot of the flight who locked his Co-pilot out of and flight deck and crashed his aircraft into the sea.
When a pilot decides to crash, the result is pretty much always mass death, but in healthcare there are frequently only short periods of time when the bad actor is alone in which they can harm their patient, and the harm is often not fatal, as we saw with Letby.
Letby won’t be the last healthcare mass murderer, and I expect we will see another murdering pilot. They just change their MO. Systems learn from mistakes.
And you mention a statistic comparing the risk of dying on a flight with the risk of suffering an adverse event. They’re clearly not the same. Most AES and non-intentional and only a tiny fraction are fatal. And yes I’m aware of the “two jumbo jets a day” headline, but that again is eye catching but misleading.
Nigel - thank you for your comment.
I agree that the "two jumbo jets" statistic is probably plain wrong, which is why I didn't quote it. The original 2-13 paper that put the number of deaths from medical error at 300-400k in the US has, I think, been largely debunked.
And of course I realise that adverse events in healthcare and deaths from air accidents are not the same thing. The comparison serves only to highlight the enormous gulf that exists between healthcare and the airline industry in terms of safety. The comparison may not be fair, given the variability in healthcare that cannot be eliminated as it can be in flying.
That said, there is no equivalent organisation to the ICAO in healthcare. If you fly into any airport in the world, the whole affair is standardised - from the letter sizing of signs, right down to the height of the grass. Every hospital, even every ward, works in a completely different way.
It is also interesting to realise - especially as evidenced in Matthew Syed's book - how little healthcare institutions are set-up to learn from each other.
While in general agreement with the point you are making (in a nutshell, that the blame culture is bad for patients safety and the inevitability of hindsight) I consider it a gross understatement to say “imagine one consultant drops in your office one day and states there is a nurse who is a serial killer”. This is not what happened. What happened was that 7 consultant pediatricians were expressing concerns over a prolonged period of time based on nursing shifts patterns, increased mortality rates and clinical incidents which were identified as sudden and unexpected. The way they were bullied by managers, as evidenced by emails shown on BBC, was disgraceful. If we are to promote a speak up, blame free culture, we need to ensure that those who speak up are listened to. Letby was eventually assigned to non clinical duties and the mysterious incidents ceased. Police, however, was not called for many more months. The concerned consultants could also have gone to the police themselves, like any private citizen would do if they strongly suspect criminal activities around them. Attention to systems doesn’t mean that personal accountability should not exist.
Micol
Thanks for sharing your thoughts. I haven't seen the emails that you speak of - although I have no doubt that the managers and the clinicians were in contention for a long time over this issue. We have all written emails that we wish we could 'unsend'. Thankfully none of mine have been scrutinised in the harsh light of national media.
And in fact my point here is that what was missing was both the culture and the systems to protect these vulnerable patients. The managers may have made mistakes, but we are not going to prevent future harm by chasing them down and punishing them.
The good news is that the new Medical Examiner role in hospitals may improve the independence of investigation earlier in the process, albeit within the same hospital. It's not much, but it's an example of the changes that could be made that will have an impact long after everyone has forgotten this tragedy.