Patient safety: err on the side of caution

I wish to add a mental health service perspective to the debate prompted by Frank Burns' insightful article 'Name of the game is not no blame' and his challenging assertions (opinion, p16, 12 April)..

Frank cogently argues that trust boards have statutory obligations to fulfil in ensuring safety and too often this is not given a sufficiently high priority..

An earlier HSJ article (opinion, p18, 22 February 2007) based on a speech by Don Berwick, chief executive of the Institute for Health Care Improvement in the US, also strongly made the case for managerial will to encourage curiosity about hazards and safety, supporting a focused and continual change to reduce risks of harm.

The issues highlighted by Mr Burns are extremely complex. Of particular concern is his assertion that fear of litigation may be a route to galvanising effective action..

Many would argue that the current anxieties associated with litigation and public scorn arise from media condemnation. This often prevents honesty, open reflection and review, leading to compromised quality of care and support and, risk averse practice in the long term.

It may be further compounded when frontline staff are scapegoated by the media, politicians and on occasions by their senior managers who may deflect the blame to preserve their own position. This evidence is found in many of the inquiries into mental health failures..

The debate for improvement should take these factors into account and consider how best to achieve fair blame when appropriate..

System failures

My knowledge of mental health service investigations is that too often individual clinicians and practitioners are let down by the absence of appropriate systems, insufficient resources and ineffective leadership, placing them in vulnerable circumstances when making vital judgements and pressurised decisions..

I am encouraged by the way many mental health services have grasped the root cause analysis approach to reviewing serious incidents and strongly caution against overzealous reactions, which may lose the positive progress already gained..

Mr Burns is right to insist that we must never be conditioned to accept mistakes but at the same time wisdom tells us that despite striving worthily to achieve, inevitably errors will occur and shortcomings will be exposed, when individuals are seeking to do their best. .

I believe it is easy for spectators to criticise the players it is much harder to play the game.

Malcolm Rae, joint lead for the acute care programme, National Institute for Mental Health in England.

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