Improving patient safety by learning from medical excellence rather than medical error

by Dr Constantinos Kanaris, Consultant, Paediatric Intensive Care and Retrieval Medicine, Cambridge University NHS Foundation Trust, Visiting Clinical Associate Professor, UNIC Medical School

Introduction by Dr Chloe Antoniou, Associate Professor in Biochemistry, Associate Programme Director for the GEMD

BRIEF SUMMARY

Patient Safety is a core responsibility of anyone working in healthcare. Stereotypically attempts to improve patient safety have tended to focus on learning from error. Even the famous axiom “Primum non Nocere” refers to focusing on harm avoidance rather than doing good.

Intuitively, this seems like a reasonable idea: if we err, we would like to understand the factors leading up to that error, learn from it and implement processes that stop it from being repeated after all, as per Menanander’s dictum «Το δις εξαμαρτείν ουκ ανδρός σοφού» (to make the same mistake twice is not an attribute of a wise person).

Mistakes, however, only happen in a minority of clinical encounters; so, learning purely from errors limits our ability to learn and improve on matters relating to patient safety. What we often miss out on is learning from occasions where patient care was excellent.

By learning purely from adverse events, we also risk creating a culture of fear, poor morale and negativity. This exacerbates emerging problems within healthcare, namely staff burnout and retention.

I aim to challenge the notion that learning from errors is the main tool at our disposal to improve quality in healthcare and patient safety. I shall also explore the concepts of negativity bias (why we are innately drawn to spot mistakes); the second and third victim phenomena as well as the value of Appreciative Inquiry. The latter is the process whereby we learn from when things go well. I will use the example of the Excellence Reporting system implemented on our paediatric intensive care unit and what effect it has had on patient care.

ABOUT THE SPEAKER

Dr Constantinos Kanaris is a consultant in Paediatric Intensive Care and Retrieval Medicine at Cambridge University NHS Foundation Trust and a Medical Expert for the General Medical Council. Dr Kanaris is a Visiting Clinical Associate Professor at the University of Nicosia Medical School and an Honorary Senior Lecturer in Paediatric Resuscitation at Queen Mary University London.

Additionally, he is the Associate Editor of the Journal of Child Health Care and is the Treasurer of the Paediatric Critical Care Society. Dr Kanaris’ research interests include bioethics, medical jurisprudence, medical education, paediatric resuscitation, and patient safety.