1. Reporting on patient safety and medical errors Richard Smith Editor, BMJ www.bmj.com/talks

2. What I want to talk about A picture A story Why did we forget? “The report” The role of medical journals The role of the mass media The role of the web The role of the WMA

3. A picture

4. A story

5. There’s nothing new about this “First, do no harm”

6. Why then did we forget it? We didn’t understand the extent of the harm We were too busy concentrating on benefit It’s painful to think about harm “There but for the grace of God go I” We thought about it in terms of culpability and didn’t know how to respond

7. “The report”: Institute of Medicine Report To Err is Human: Building a Safer Health System Put safety to the top of the US health agenda Every country needs one

8. The role of medical journals

9. What journals can’t do Make change happen straight away: “Words on paper don’t change things” Tell people what to think

10. What journals can do Disturb, stir up, encourage debate Set agendas: “Tell people what to think about” Legitimise: “If the NEJM is talking about safety it must be important”

11. The role of medical journals Reporting scientific data –how many errors? –what type? –why do they happen? –what should be done about them? Raising consciousness Setting the agenda Educating

12. Reporting error: USA Harvard Medical Practice Study Published in the New England Journal of Medicine in 1991 In 3.7% of hospital admissions an adverse event led to harm

13. Reporting error: Australia Australian study Published in the Medical Journal of Australia in 1995 An adverse event occurred in 16.6% of admissions

14. Not reporting error: UK “If the [US] results apply in then about …45 000 may die in part because of the [adverse] event…Every country needs such a study…” BMJ editorial, 1990

15. Violet Vanbrugh

16. Setting the agenda Raising consciousness Educating

18. How to reduce error Quality improvement reports Context Problem Measures of improvement Information gathering Strategy for change Effects of change Next steps

19. Journals specifically concerned with safety

21. The role of the mass media Reporting cases to the world: the world is interested Reporting data Explaining error: Why does it happen? What can be done? Generating political commitment for improvement

22. The role of the web Enormous potential for sharing High quality information Tools Experiences Contacts Many websites are appearing and will appear

23. Purpose of Qualityhealthcare.org Help improve the quality of health care worldwide Be easily accessible free or at very low cost Provide trusted content and tools to improve healthcare Put experts throughout the world in touch with one another

25. The role of the WMA Raise consciousness Convince member associations that they should be thinking about this issue and doing something Put them in touch with people who can help them Produce a grand statement that commits members to improving patient safety