What episode of avoidable harm to a patient had the greatest impact on you as hands on, observer or Investigator? What did you learn?

I was in a team when new Doctor mixed antibiotic with potassium not sodium chloride & injected into central line, patient died.

Systems matter. I am running a seminar on #PatientSafety & Leadership & want real examples of Avoidable Harm & effective changes.

In my example it's now unusual for concentrated potassium chloride to be available on general wards, but that took far too long.

@NHSwhistleblowr @BrennanSurgeon

Misdiagnosis and Cognitive Overload in the Clinical Workplace causing Morbidity and Mortality. Look at the notes pages in this PowerPoint. 10 Quality Indicators for Clinical Consultations

dropbox.com/s/niz0e1h1hc7k…

@HumanRiskLtd @nialldowney @TheIHI @AndrewElder @cuttingforstone How to create conditions for Misdiagnosis that can kill or seriously harms patients.

#PulmonaryEmbolism

#AddisonsDisease

and Counter Measures

#DiagnosticCockpit dropbox.com/s/qkbpmcxe85b0…

Just now Right now

humanriskpodcast.com/dr-gordon-cald…

We need to Run Faster than Diseases Progress in Patients.

So much #NHS Hospitals can do to unblock A&E & Wards without waiting for more Social Care - #CutTheCrap

@mnt @BBCr4today @BBCNews @TheIHI youtube.com/live/Z8Kkg20G7… for those who prefer video to podcast - starts at 12:04pm #NHS Drowning in Paperwork

It’s interesting I’m being told how long is ideal in #NHS for Clinical Consultations in Outpatients by ‘management’, who can hold as many meetings of undefined purpose and length as they wish at short notice & expect my participation @djnicholl @PeteGordon68 @vincentconnolly The most important Meetings in #Healthcare are between Patient and Clinician but are not the ones valued and prioritised by management

dropbox.com/s/vd7fybw50ml9…

I don’t think of myself as a great doctor but I know there is no success in medicine without preparation and organisation therefore I have just spent 2hours organising our inpatients medical case note folders after today’s #WardRounds @DrGrumble @CLOSLER @j59dd I don’t know what had happened in the 3 weeks since my last Physician of the Week but someone must have decided that entropy into chaos was the best way to organise inpatient clinical notes and won everyone over. Entropy is easy, organisation is unremitting hard work

Yes, that’s what I trained for too

I weep watching our Junior Doctors wrangling with dreadful disconnected paper & computer IT which gobbles up their working time & undermines their Clinical Reasoning thus putting Diagnosis & Patient Management at risk

https://twitter.com/smudge142/status/1195879784527671296

At a ‘Winter Pressures’ meeting on Friday I said we could make our already good 4hr performance an hour better if we had Usable IT and cut out the quintuplication of information into multiple different bad paper & computer IT systems @acutemedicine @PeteGordon68 @nhshBoyd

#DNACPR or Will For The Final Stages of Dying?

dropbox.com/s/7ybniuov566r…

I observe that every Consultant struggles with DNACPR because of the negative framing. We (I?) must change the framing

@JohnLauner Consultants & Juniors at #FortWilliam like this

You are not dying now
Your health is frail
One day your health will deteriorate badly and
We will know you are dying and
What should we do for you then?

Patient usually answers

Let me go, Doc

dropbox.com/s/7ybniuov566r…