Prof James Reason's swiss cheese model (from BMJ 2000; 320: 768-70)

Jane and I got very excited yesterday when we heard that Prof James Reason was talking on Radio 4 on Monday night about medical errors. Prof Reason is most famous for his swiss cheese model (above), and when anyone talks about human factors research, or safety in organisations, his swiss cheese model is the first thing that springs to mind. He is that good and that famous!

The radio programme called Dr – Tell Me the Truth is a two-part programme hosted by James Reason about medical errors. What I really enjoyed about yesterdays episode (the next one is on Monday 27th February 2012) was hearing from a range of stakeholders in medical errors. During the programme we heard from patients, researchers, clinicians and lawyers all relating their experiences of when errors had been brushed under the carpet and when clinicians had been open and up front that they had made an error. There was even an excerpt from a qualitative interview of a patient who had experienced a medical error in her cancer treatment and subsequently enrolled in a research project with the University of Michigan. In this excerpt you heard the patient say that she had the opportunity to talk to the clinicians that made the mistake and tell them how she was so cross at herself for not speaking out more in her consultations and not pushing until she got the response she needed. One of the clinicians there turned to her and said it wasn’t her fault (which obviously it wasn’t). The patient said when recalling this meeting that this simple experience made her feel listened to and not ignored and not like this error which was to have a huge impact on her life and health was not being swept under the carpet and ignored. This same theme was echoed again and again, where patients reported just being told that an error had been made, and being able to talk to the Doctor about it helped so much. The University Of Michigan had also been involved in lots of initiatives to create hospitals where doctors were completely open about errors. At first everyone was worried this would lead to more litigation, especially in cases where patients did not experience any ill effects of the error and did not know it had happened. However, what they found was the opposite that it actually dramatically reduced how much they were paying out in compensation for medical errors see here.

Next week they will be hearing from Sir Liam Donaldson about whether the same principles could work for the NHS. Also from other healthcare professionals. I am hoping we hear from a pharmacist too in the next programme. There are so many professional groups in the NHS that it would be a shame (and biased) if they just talked about errors made by doctors.