I’m nearly a junior doctor! What do I know about keeping people safer? – Philip Riddell

This question has vexed me since the first time I became involved in patient safety. I’ve spent the last three and a half years learning (and re-learning) anatomy, physiology, biochemistry and pathology. I’ve gone from a ‘lay’ twenty-three-year-old science graduate, to a final year medical student. In just six months, I will (hopefully) be a junior doctor.

That last thought sends a shiver down my spine. I will be a key part of the ward-team in whichever hospital I am sent to. Most of the questions about a patient’s care will be directed to me in the first instance. I will do the bulk of day-to-day prescribing and be one of the first staff members to respond to any emergencies. Most importantly, I will see when things go wrong.

On reflection, I believe that my course has equipped me with the knowledge and skills that I need to perform my day-to-day tasks as a junior doctor. Unfortunately, I do not feel as prepared to tackle patient safety issues as and when I notice them. That is something that I can change myself in the next six months and by sharing my experiences, I can try to help future students when they find themselves in the same position.

I do not attribute my lack of preparedness to a lack of awareness about specific types of harm. As students, we received teaching on many ‘common’ errors and how best to avoid them. For example, I understand that writing ‘U’ as shorthand for ‘UNITS’ is a disturbingly common way for excessive, sometimes even lethal, doses of drugs to be given. I have even noticed errors myself and prevented patients from coming to harm during my time as a student. The response of staff members in these situations has been encouraging.

The Clinical School here at Cambridge was one of the first to introduce ‘Patient Safety’ as a topic for teaching, with a focus on preventing specific types of harm (like the dosing error mentioned previously). I feel there is an opportunity here for the school to also teach the underlying principles of patient safety that can have an impact on all areas of harm and error. The Clinical School does run sessions that aim to achieve this, but as students we end up focusing on specific harms for the entire session. We need to be encouraged to move past this superficial discussion on specific harms and focus on the general principles that lie behind them.

These principles have only become clear to me after I have reflected on all the safety incidents that I have been involved with during my medical training to date. They all focus upon communication and culture:

  • Listening to the concerns of patients, staff and their family members and encouraging them to express their opinions without fear of judgement
  • Speaking up when I feel that something is not going according to plan, no matter how far down I am in the medical hierarchy.
  • Being open and honest with everyone when things do go wrong

The distinction between harm specific and general principles in patient safety became clear to me at a recent lecture given by Dr Sue Robinson, the Deputy Medical Director of Cambridge University Hospitals Foundation Trust, on Clinical Governance. When we as final year Medical Students were asked what ‘Clinical Governance’ meant, it took a considerable length of time for us to collectively define this topic. Subsequent discussions around the subject highlighted the same problem – we simply could not see the woods for the trees. Many could name specific examples of how to keep our patients safer, but only a handful of us could talk openly about the underlying principles. I was thoroughly congratulated for contributing the idea of a ‘just culture’ to the discussion, but I was surprised to find that many in the room did not know what this meant – they had only ever heard the term as ‘sound bite’. How are we as future NHS staff supposed to create a just culture if we do not really know what it means?

All the medical students at that lecture will become frontline NHS staff this August. Some of them will progress to work specifically in the fields Clinical Governance and Patient Safety. If we cannot define the underlying principles of safe healthcare, how can we begin to utilise them to help keep people safer?

I think being able to fully cover these fundamentals of patient safety and safety culture would require more training hours than I experienced. However, I believe that with a modest amount of training, newly qualified staff could begin to understand these principles. This understanding would help staff to share what they know about keeping people safer – we could begin to rely on each other to keep our patients safe and ultimately move away from the blame culture that some people working in healthcare face. That said I also feel it’s so important for us (students and juniors doctors) to always feel able to seek help and not feel we need to shoulder the responsibility for patient safety solely on our shoulders.

This is not something that will happen overnight. Meaningful change is hard to achieve, particularly within complex organisations such as the NHS. Multiple teams, whether that be in clinical microsystems, specialities, hospitals or trusts all interact to produce what patients experience as their own healthcare.  This increasing complexity can contribute to why errors happen, but I believe that this can also provide us an opportunity to reduce patient harm by exploring multiple perspectives of the same incident. If we had the tools and the confidence required to share our unique perspective during our early careers, we could make a huge impact on the safety of our patients.

We also need to ensure that students are fully engaged with patient safety – their own perspective can often be one that no other healthcare professional can truly see.

I believe that discovering these underlying principles is the first step in sharing what we know about keeping people safe and is something that could be nurtured more during the training of all health professionals.

I now have six months to build my confidence in sharing what I know about keeping people safer before I officially start work. Let’s see how it goes.

Questions I ask myself to help improve my understanding of patient safety

  • What incidents have I been involved in? How did I react to those situations and what does that tell me about my understanding of these underlying principles?
  • How did other people react in these situations? Was that something that I appreciated, or did it have unintentional negative consequences? Does that impact on how I will react to situations in the future?
  • How can I best facilitate the sharing of ideas? Sharing ideas can help others reflect on what their own thoughts are.
  • What perspective can I provide here? You often experience things in ways that other staff members do not due to your own unique perspective
  • How will I use these underlying principles to promote a culture where people share what they know about keeping people safer?
  • Who can I ask for help about this?