UK Chief Medical Officer Urges Patient Safety Measures

One of the world's most prominent health care leaders, Sir Liam Donaldson, MSc, MD, chief medical officer of the United Kingdom and founding chair of the World Health Organization's Alliance for Patient Safety, gave a talk on Monday, Aug. 28, about medical errors and approaches to hospital safety. In the talk, titled "Patient Safety: A Global Challenge," Donaldson explained that while the scope and nature of medical errors and patient safety are well understood, there is much work to be done in order to make an impact and improve the system. To that end, he outlined challenges health care leaders should undertake in an effort to make these changes and improve patient safety. Challenges included acknowledging the roles individuals play in creating medical errors, as well as the systems they operate in; changing how health care institutions learn from mistakes; creating a culture of safety; investigating errors of omission, as well as commission; and transforming services. "We need more individuals dedicated to examining errors and working to ensure they do not occur again in the future," he said. "Patient safety programs should include, at a minimum, a reporting system, root cause analysis and a team of dedicated individuals to examine it in order to provide safe and secure services." This occurs in other fields, such as aviation, but not in medical practice. Donaldson explained how in the UK, once a doctor has finished residency and is in practice, there are no performance assessments for the remainder of his or her career; whereas in aviation, commercial pilots have approximately 100 performance assessments throughout their careers. Using real-world examples of young patients who died due to a medical error and the testimonials of surviving members of their families, Donaldson also explained that rather than one fatal mistake, there are often many factors that contribute to a medical error occurring. In one example, a post-analysis of the case revealed that 40 different mistakes led to the ultimate medical error causing the patient's death. "What is amazing about these families is that despite the horror they have endured, they are not asking for retribution. They ask only that the medical establishment honor the memory of their loved ones by never letting it happen again," Donaldson said. "We must do this." While visiting here, Donaldson planned to tour UCSF Medical Center's facilities and learn about its efforts to improve quality and safety. He also planned to meet with members of the UCSF community involved in efforts to build world-class information technology systems, decrease the chances of medical errors, such as leaving sponges and other surgical instruments behind, and improve teamwork and communication between doctors and nurses. Donaldson was the invited guest of Robert Wachter, MD, professor of medicine, chief of the medical service and chair of the patient safety committee at UCSF Medical Center. Monday's lecture was sponsored by Wachter and the Gordon and Betty Moore Foundation.