The June meeting used the Patient Safety – learning from Human Error module. This was a really useful module as it was less didactic and the members really got into it. The examples from other industries and professions was a good way at analyzing what we do. The ‘sterile cockpit’ analogy was something we all agreed could be used, for example, simply by shutting down Outlook and re-opening it at lunchtime. This would allow us to remain undisturbed by e-mails.
Themes discussed during the session invariably led to how unsafe DMICP is especially when it is not accessible. There were some positives though. For example, the hospital referral template letter was shared. The two week wait Macro enters some text plus the READ code to be used (2WW). We talked about making a Macro for routine referrals as well. The use of taskers was also discussed and since the meeting I have adopted this for my own practice. The tasker menu can be modified in its setup to send admin taskers to oneself.
One of the module case studies looked at the Kegworth air disaster when the pilot shut down the wrong engine. Despite all the passengers knowing this, no-one did anything about it. The captain is always right. I prefer the comment of one of my favourite chefs, Nino Ladenis, who said ‘the customer is not always right’ (this related to a customer requesting tomato ketchup for his Michelin three starred meal). We went on from this to talk about an anonymous safety reporting system but agreed if the SEA/PSIR system is working well and you foster a climate of open reporting and no blame, this is not necessary.
Several resources were discussed. Jennie has since circulated her task sheet and the book ‘Do It Tomorrow’ was mentioned. The use of taskers for electronic referrals at Bulford is impossible due to the number the Practice Administrator gets (5 to 20 notifications a day for confidentiality breaches).
It will be interesting to see how everyone gets on with looking at access to them and how they can manage that. It would be useful if members can look at their own practice and reflect on it. When was the last PSIR you had down to human error? How can you mitigate when DMICP goes down?