Stephen Ramsden on patient safety's missing link

Stephen Ramsden

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I remain vexed by the question "how can we engage junior doctors in patient safety?"

Despite a number of years at Luton and Dunstable Hospital foundation trust spent building on our own patient safety and implementing the Safer Patients Initiative, I feel there has been a lack of engagement with junior doctors.

There are two repercussions of this omission. Juniors are at the front line of patient care so the potential for error is great. Second, they are the clinical leaders of the future: their focus on safety will impact on their teams and the next generation of doctors.

In grappling with the challenge of the European working time directive, the focus seems to have been on the problem of how to cover a reduction in working hours rather than a detailed look at how those hours are organised.

This was brought home to me when I shadowed a post-take ward round. There were nine doctors hovering around each patient (partly due to a nightshift handover). It was unclear who was doing what or even who was taking responsibility for what. The organisation of the round felt chaotic and was hampered by shortage of space, of computers... I could go on. If anyone has developed the "productive medical team", I would be very interested to hear about it.

All of which makes me extremely nervous about the potential for error. A consultant safety lead recently reported on a mini-audit of prescribing competence he had done with a new intake of juniors. Of 22 participants, 17 failed the test, having prescribed a penicillin-type drug to patients with an identified allergy. This was despite an educational session before the exam.

The transient nature of junior doctors' time at the hospital can mean their formal and informal networks are weak. We risk compounding this with attitudes such as "they are here for such a short time" and "of course it wasn't like this when I trained".

This is not to underestimate the challenges that frequent shift changes and the movement of juniors around and out of the organisation bring, but we need to put more effort into our relationships with them. Most junior medics never meet a trust chief executive during their training, so we need to go to them, not expect them to come to us.

Junior doctors are interested in safety and improvement. I have been given excellent advice from some about how to engage them in patient safety. And 40 doctors (juniors and consultants) met me recently to explore their practical engagement in the safety drive at the hospital.

They can point to where there are high risks, for example in handovers, and identify possible improvements as well as how traditional hierarchies within medical teams can hinder open communication. They will consider focusing their audit projects on work related to patient safety.

We ignore the role of junior doctors in maintaining safety at our peril. But engaging the talent, enthusiasm, and direct frontline experience of tomorrow's clinical leaders will bring a much wider set of benefits to the whole NHS.

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