The first morning ended with a briefer than intended panel discussion led by Denis Smith, with Carol Black (RCP), Anna Walker (HC), Nick Bishop (HC) and Doug Russell (Tower Hamlets PCT). The discussion struggled to get off the ground with the panelists philosophically prevaricating over definitions of ‘safe’ and ‘who for?’. The eventual conclusion was ‘not safe enough’.
The inevitable parallels with the aviation industry reappeared though one commenter usefully pointed out that (unlike aviation) healthcare is not a simple interaction between people and systems—there is this confounding thing called disease to consider as well. There was much bemoaning the pervasive culture of blame, and how the legal system and media push for a scapegoat at every opportunity. One questioner pointed out the errors are often multifactorial or multistep and the sometimes the least significant contributing step is the one singled out for blame. There was also concern that the culture is engendering fear and defensiveness at an early stage of training, and that organizations that have high error reporting rates are frequently assumed to be ‘bad’, when the opposite is more likely to be the case.
