Sir Liam Donaldson, Associate Fellow, Centre on Global Health Security, keynote address

2. A CASUAL OBSERVATION

3. A CAUSAL OBSERVATION
I undertook outpatient phenol sclerotherapy for
symptomatic second degree haemorrhoids on a 58 year old
lady. I use oily phenol 5% BP w/v, and injected 2-3ml at 4
sites into the submucosal area at the base of each pile,
above the dentate line. On this occasion, I was passed the
phenol already prepared in a syringe. I didn’t check the
phenol composition but it was subsequently determined to
be an 80% aqueous solution. Post-injection, the patient
developed necrosis at the upper border of the ano-rectal
canal, which necessitated surgical debridement and
defunctioning end-colostomy. The colostomy was eventually
restored successfully with full patient recovery after some
months.
Source: CORESS, Royal College of Surgeons England, March 2010

4. Week 1 – retained swab
Week 3 – retained instrument
Week 4 – wrong site
Week 6 – wrong implant
SURGICAL ERROR:
A WORLDWIDE PHENOMENON

5. January – wrong site
neurosurgery
July – wrong site neurosurgery
November – wrong site
neurosurgery
SURGICAL ERROR:
A WORLDWIDE PHENOMENON

6. LAC-MÉGANTIC: ANATOMY OF A
DISASTER

7. STORIES FROM THE HEART

8. THE SEEDS OF DESTRUCTION

9. PRE-FILLED SYRINGE CONTAINING VINCRISTINE
ILLUSTRATING THE WARNING WRITTEN IN BLUE TEXT

10. WHO IS TO BLAME?

11. STORIES FROM THE HEART

12. Tragic
death
Team cultureFully-trained
staff
Procedural
guidelines
THE GAPS
Professionalism
of staff
Good
communication
Not followed
Insufficient experience
Hierarchial attitudes
Inappropriate attitude
Risks not highlighted
DEFENCES
PROMOTING SYSTEMS THINKING

13. NASOGASTRIC TUBE INCIDENTS
REPORTED AS ‘NEVER EVENTS’
Source: NHS England
2012/2013: 20 cases
2013/2014: 14 cases

14. PATIENT SAFETY – THE TURNING POINT

15. Apathy
Incidents
seen as
parochial
events
Disinterest
Patient safety
was the
domain of
academics and
enthusiasts
THE STATE OF SAFETY IN HEALTHCARE
AT THE BEGINNING OF THIS CENTURY
Condescension
Information
withheld
from victims
Ignorance
Scale of
problem
unrecognised
Arrogance
It could not
happen here
© Sir Liam Donaldson

16. PATIENT SAFETY INCIDENT
REPORTS IN ENGLAND AND WALES
Source: The National Reporting and Learning System

17. PATIENT SAFETY INCIDENTS
REPORTED IN THE NHS
Source: The National Reporting and Learning System
Deaths
(31,600)
Severe harm
(67,400)
Moderate harm (624,000)
Low harm(2.55M)
No harm (6.97M)

18. “Commenced night shift short-staffed. Dr in charge was a
locum, newly qualified and unable to administer IV
medications. RN is agency nurse. Only saw 2 out of 10
patients. Dept over full with many patients on trolleys.
Shift was unsafe with reduced numbers of staff, who were
inexperienced and lacking skills.”
Source: NRLS
EXTRACT FROM PATIENT SAFETY
INCIDENT REPORT

19. THINKING SYSTEMS: INTERFACES
AND INTERACTIONS
ENVIRONMENT
PEOPLE
PROCEDURESMACHINES
Source: Donaldsons’ Essential Public Health. London: Radcliffe, 2016

20. TEAMS DETERMINE SURVIVAL AND DEATH

21. PROTECTION PATIENTS:THREE PILLARS
Identifying
harm
Learning
from error
Improving
safety

22. PATIENT SAFETY GOES GLOBAL

23. PROGRESS OVER THE LAST DECADE
Systems thinking
Scale of problem recognised
Human factors appreciated
Successful campaigns
Growth of simulation

24. DISAPPOINTMENTS OVER THE LAST
DECADE
Few actionable data
Lack of effective solutions
Limited practitioner interest
Patients seldom involved
Risk not communicated widely

25.  Clinical Staff take a wider perspective on their work.
 Acceptance of standardising practice in some areas.
 Problem-solving culture.
 Quality plan and business plan are one and the same.
 Involvement of patients and families.
 Good use of data.
KEY FACTORS FOR SUCCESS

27. 1:300 1:10,000,000
COMMERCIAL AVIATION VERSUS
HEALTHCARE: COMPARATIVE RISKS

28. Source: Donaldson L. When will healthcare pass the orange-wire test? The Lancet 2004;
364: 1567-1568
GLOBAL ACTION TO SAVE LIVES