Stephen Ramsden on harm to patients

There has been an outcry about hospital-associated infections. Media sensation about "dirty hospitals" has succeeded in putting pressure on government to do something. Is this because it seems easier to understand? Or has it just simplified a complex problem?

Safety is complex. My trust's non-executive directors cannot understand why our hand hygiene compliance scores are only 93 per cent and not 100 per cent; we executives cannot believe they are 93 per cent. So when a more robust audit showed it to be actually about 45 per cent we acknowledged the size of the problem.

We are frustrated by our poor understanding of why this seems a difficult behavioural issue to address. But how difficult it is to talk about these issues became clear to me during an interview with a national newspaper. I was trying to describe our hospital's approach to managing "acutely ill deteriorating patients". The conversation went something like this:

Reporter: "What do you mean?"

Me: "Failure to rescue sick patients who are getting sicker."

Reporter: "Sick patients are getting worse and it's not being spotted? What exactly do you mean?"

Me: "Our nurses seem to have lost the art of taking reliable observations."

Reporter: "You mean the very sick patients are not getting their vital signs monitored?"

Me: "Not exactly. Some basic observations, like taking respiratory rates, seem to have stopped being taken reliably when machines like dynomaps were introduced. They do most vital signs mechanically, but not respiratory rates. So we had to retrain people to do reliable observations and gave them an early warning chart to make it simple to identify when a patient is deteriorating."

Reporter: "Absolutely staggering, but at least you've now resolved it."

Me: "Not quite. For some reason we still have examples when the observations have not been done or not acted on when a warning is triggered."

Reporter: "Why on earth not?"

Me (embarrassed): "I don't really know."

Reporter: "But patients are dying because they are not being observed."

Me (sheepishly): "Yes, that's the rub of it."

Of course, we have been working hard to resolve this and did reduce our weekly cardiac arrests by 50 per cent. We are saving lives but failure still happens - probably in every hospital.

Let's do something about it. You can do so by joining the Patient Safety First campaign, which is promoting tools and interventions to improve this situation.

I can foresee similar uncomfortable meetings with journalists (and the board), perhaps on pressure sores, malnutrition or medication errors. This is a scandal but goes largely unreported. Maybe we don't believe the figures. Maybe we just turn a blind eye to it - it has always been like this. Or maybe it is the dead moose in the room that nobody wants to talk about.