I worked as a Doctor for NHS for 42y from 1980. I live in Ballachulish, Scotland.
Nov 12, 2023 • 9 tweets • 2 min read
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
Feb 8, 2023 • 7 tweets • 7 min read
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
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
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
Nov 17, 2019 • 4 tweets • 3 min read
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
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
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?
How to create conditions for Misdiagnosis that can kill or seriously harms patients. 
