NHS culture avoids blame when the priority is avoiding deaths, says report

NHS culture avoids blame when the priority is avoiding deaths, says report:

NHS Alliance, an independent medical lobby, wants a system that will study errors so that lessons will be learnt

Out-of-hours GPs and other primary care organisations are failing to admit potentially fatal mistakes or use formal alert systems designed to prevent similar accidents, according to a new report.

There is a "culture of avoiding blame" when the emphasis should be on avoiding deaths, the report, published by the NHS Alliance, said.

The alliance represents doctors, managers and commissioners, and is trying to persuade about 100 organisations providing emergency evening and weekend GP care for 7 million people a year in England to join an anonymous system.

This is being piloted by 10 organisations following the scandal involving Daniel Ubani, a German doctor who accidentally killed a 70-year-old patient in Cambridgeshire with a 10-fold overdose of the painkiller diamorphine.

An NHS investigation into the incident accused Take Care Now, a now-defunct out-of-hours provider, of systemic failings, including not heeding national safety warnings on the administration of drugs or sharing information on poorly performing doctors.

The NHS Alliance, backed by the Department of Health, the Royal College of GPs and national safety watchdogs, is trying to develop a new anonymised website and teleconferencing system to highlight errors and ensure lessons are learned.

The need for better links between out-of-hours and regular GP services on the one hand, and pathology labs and A&E departments on the other, are among the issues that have been raised.

The report said that the Ubani case "highlights how slow we often are to learn from mistakes, both within organisations and across the wider urgent care system". It adds that there is still "a very low level" of recent incident reporting using official NHS channels "both from out-of-hours and primary care as a whole", and it hoped the initiative would "shift the way providers think about incidents, giving them cultural permission to admit that occasionally we mess up".

Rick Stern, who is in charge of urgent care for the alliance, said new rules and guidance were not enough. "One of the biggest failings is the culture of avoiding blame and the lack of good systems for sharing what has been learnt," he said.

The alliance did not want to replace official reporting systems even though they were poorly used, he added.

The NHS's National Patient Safety Agency, which runs the formal incident reporting system, is being abolished as part of the coalition government's closure of quangos, but it is in talks with Imperial College NHS Trust in London to run the system for two years before it becomes the responsibility of the NHS commissioning board. The Guardian