mat daniel mini logo

Doctors at Work Podcast.

Episode #58

How to prevent and manage adverse healthcare events

Mat Daniel


Patients are at the centre of what we do, yet  they are also at risk of harm from adverse events related to their healthcare needs. And when errors happen, doctors are affected too. In this episode, Gordon Caldwell shares his experiences of managing and preventing adverse events. He stresses the importance of creating a culture that encourages everyone to speak up. His top tips for preventing errors is to create systems, checklists, and routines that ensure a focus on all aspects of care not just the obvious and urgent.

Dr Gordon Caldwell was a medical student at Oxford and Kings. He trained in General Medicine, Diabetes and Endocrinology at King’s, Brighton, Edinburgh, RPMS London and Newcastle upon Tyne. He was a Consultant in Worthing from 1993 to 2018 and Oban Hospital 2018-2022. His particular interests are in the use of IT at the patients’ side, medical training and quality and safety at the point of care. He now lives in Ballachulish on the west coast of Scotland.

You can also watch on

Podcast Transcript

[00:00:00] Mat: Welcome to Doctors at Work. My name is Mat Daniel and this podcast is about doctors’ careers. Today I’m having a conversation with Gordon Caldwell and we’re talking about how to prevent and manage adverse healthcare events. Now patients are at the centre of what we do but they are also at risk of harm from adverse events related to their healthcare needs and when errors happen doctors are affected too.

In this episode Gordon shares his experiences of managing and preventing adverse events. He stresses the importance of creating a culture that encourages everybody to speak up. His top tips for preventing errors is to create systems, checklists and routines that ensure a focus on all aspects of care, not just the obvious and the urgent.

Welcome Gordon. Tell me a little bit about yourself.

[00:00:46] Gordon: I’m Dr. Gordon Caldwell. I’ve actually retired from the NHS now. I qualified as a doctor from Oxford and King’s in 1980 and trained through King’s, Brighton, Edinburgh, the Royal Postgraduate Medical School and Newcastle area training in general medicine, diabetes and endocrinology.

Then I was a consultant in Worthing from 1993 through to 2018, and then did four years as a consultant in a small rural hospital in Oban. And my particular areas of interest were very much cantered on patients patient care, medical education, use of it, close to the patient and laterally quality and safety in healthcare.

Thank you.

[00:01:30] Mat: Thank you. So today we’re talking about healthcare adverse events. So what is a healthcare adverse event?

[00:01:37] Gordon: For me, it’s an adverse event is something that’s very likely to harm a patient or harm staff or harm both. So it’s something potentially avoidable. So rather than the side effect of a medication which had to be prescribed septicaemia after chemotherapy, it’s a mistake, an error, something that’s happened that’s resulted in harm to patients.

And because of healthcare staff’s concern for patients is very likely to harm them as well, at least undermine the confidence and certainty about the way that they’re working and behaving. So it’s something that happens clinically, it’s in the clinical workplace, and it’s likely to harm patients and likely to harm staff as well, and also potential to harm the reputation of the organization.

[00:02:21] Mat: Can you give me some examples?

[00:02:23] Gordon: Obviously over a career of 42 years, there are a lot of examples. I think the first one that really struck me was towards the end of the 1980s when I was a senior registrar, and it was the first day in August when the houseman started, and the houseman on the team was asked to go and give intravenous antibiotics.

to a patient through a central line. And the houseman went into the side room where in front of him was the antibiotic vials and vials of sodium chloride and potassium chloride. And unfortunately, the houseman mixed the antibiotic up with the potassium chloride. The vials look very similar. Then went and administered the antibiotic through the central line and the patient died.

So that’s the worst sort of severe adverse reaction because the patient’s dead, clearly avoidable and would have, I’m sure, a terrible effect on the houseman’s career, as well as on the reputation of the organization. And that, to me, I think, got me started thinking about what are the processes, what are the how are things organized and designed?

To create safety because in those days, potassium chloride vials looked identical to the sodium chloride vials. They were freely available on the ward. We’re adding them to giving sets and things all the time. Whereas now, potassium chloride is treated much as a controlled drug in the NHS. Is kept away from the wards as much as possible locked in cupboards to emphasize how dangerous it is.

So that was something way back in the 1980s, which was clearly a risk. I don’t think it’s been completely dealt with yet, but that emphasized to me again, how dangerous. It is for a patient being in hospital. I liken it to walking along a cliff, clifftop path. You’re trying to take a blind man along the top of a cliff, clifftop path at night in bad weather.

And we’re used to doing that. We know every twist and turn of the path, but if we let go of the patient, they can so easily just go over the edge.

[00:04:22] Mat: Yeah, I have to say, I remember those days when potassium chloride looked exactly the same. And if you look at back on that now, Gordon, you think, what were we thinking?

Why did we design something that was so obviously dangerous? And I suspect your incident isn’t the only one, because I remember there probably been a number of incidents around that era where it really popped up, didn’t it? And yes, what were we thinking?

I think a whole, when you said design, I think a lot of stuff in health care happens by happenstance rather than design, and people haven’t thought about design for safety.

[00:04:58] Gordon: Even now is, I worked the last hospital I worked in, the junior doctors had to work out the doses of gentamicin more or less in their heads. Rather than having a spreadsheet with the calculations included in there, so wide open for mistakes and errors. And so I don’t, again, in healthcare, a lot of things obviously were designed for safety, a dialysis machine, a coronary artery bypass circulation, very clearly designed for safety.

But actually, in the mundane day to day work, I don’t think there’s much designed for safety.

[00:05:32] Mat: The interesting thing there, is if any young doctors are listening, there’s probably a bunch of stuff out there that could do with being redesigned and great opportunities for projects and service improvement is to look, these kinds of things they all still exist, my, my example is there’s a, There’s a guideline that, that apparently exists, except that it doesn’t, as in it’s not published anywhere and the version that exists is a draft version, but obviously we’re all working to that.

And I kind of thinking, what is it’s not published anywhere, the bit, some people have it on email, it’s got draft written all over it and we all work with that and you think. That’s bad design, isn’t it, Stratham? Yes.

[00:06:12] Gordon: And when you’re talking about, junior doctors and quality improvement, a lot of it is really difficult and well beyond getting all the changes for potassium chloride.

I couldn’t possibly achieve that. All I could do was make sure that the story was well told and we’re still talking about and we’re not covering it up. So I think at a very junior level, when you see things go wrong, don’t turn a blind eye. Talk about it is really important because the more we talk about these things and we’re honest and open about them, the better the chances that something will get changed.

We’ll probably talk later on about the changes you can make at your individual level. To increase safety, but some of these projects are huge. I think most of the information technology systems in hospitals and their relationship between primary care and secondary care are terribly dangerous and poor in terms of patient safety.

I didn’t realize, for example, when I moved from England to Scotland, you can no longer see any clinical information about an NHS England patient at all in Scotland. We’re completely sealed off and vice versa. If a patient comes from England to Scotland with an anaphylactic reaction to penicillin and they’re septic in our A& E, we could kill them by giving them the antibiotic because we don’t know the information.

Now, again, a junior doctor can’t. Change that system other than talk about it and say how dangerous and difficult it is.

[00:07:37] Mat: I think there’s something there that I guess there’s probably no one individual that can change the system, probably. But it’s for all of us to change systems, isn’t it? I think, when particularly early career doctors, if they do see a mistake, I suspect a lot of them are quite wary of speaking up because, I don’t want to or I’m going to get a label or people are going to get annoyed with me.

So I think it’s quite hard for people to,

[00:08:03] Gordon: yes I think that’s, it’s very difficult. And it’s our job as the leaders and the consultants to make sure that the atmosphere and the culture within a team is clearly open for people to talk. We eventually developed a system of standardized review of our patients on the ward round, backed up by a checklist to make sure we’ve done it.

So I used to get the medical students on our team to handle the checklist and tell them that they had the most important job of the day, which is to make sure we’ve done everything. And this included things like, have we checked for a urinary catheter? And if we had, should it be removed or left in? So down at that sort of level.

Now, I told the medical student. That’s what I wanted them to do. And then if they were being reticent about it, I told them I really did want them to say they hadn’t seen me check for a canning or whatever. And then within our team, they recognized that Checking up and pointing out errors and averting harm was important, but equally, once they’re finished with us, we have to say, be careful when you go to the next unit and judge what the character of the consultant is like, because if they’re like me, they’ll welcome it.

But there are a proportion of consultants who I suppose the old style James Robertson Justice type of consultant who would just pull the student out and say, you’ve got no right to, to speak up in my wardrobe. So it’s, we have got also a poor inherited culture, I think, within the medical profession that the consultant is God, knows everything.

isn’t to be questioned and never makes mistakes. And it’s all the other consultants who make mistakes.

[00:09:45] Mat: Okay, so you’ve outlined that very clearly that speaking up happens because you’ve given people permission, you’ve explicitly given people permission. And not only have you given them permission, you’ve told them that you expect them to speak up and you’ve invited challenge.

permission, you’ve told them that you expect it, what else can senior doctors and senior leaders do to create to encourage people to speak up when it comes to patient safety?

[00:10:11] Gordon: Again, going right back to when the student arrived, I think just showing an interest in the person. Whenever students or junior doctors arrived working with me for the first time, I always made sure I knew who their name was, which medical school they were from what their interests outside medicine were, even on the busiest of post take ward rounds, do that.

Because if you create a relationship, With your staff, they, then you’re creating team working and a clear objective as to what you’re trying to do. So I think that at a very simple level, spending that one minute, getting to know who the people are and introducing them and making sure everybody knows who each other is vital.

In Worthing Hospital, they introduced the huddles every morning. I don’t like the word huddle, I’d much prefer pre work briefing or whatever than huddle. Within that. There was making sure that everybody knew who each others were. If there was a new ward orderly, then who is this person? And so I think to create an atmosphere of safety is making sure everybody knows each other, trusts each other, talking about the mistakes.

Again, I’m not a very great advocate of the Datix system because it doesn’t seem to work, but supporting systems that are concerned with safety and working towards making systems better and showing that you’re interested and concerned about it. So I think showing that commitment.

[00:11:34] Mat: What’s Datix system?

[00:11:37] Gordon: It’s, to me, first of all, it’s very computer cantered and the systems that I’ve seen have all been maybe six or eight screens of questions that you have to answer as the reporter. Now, I’m very IT literate, and I used to be daunted at the thought of going through it, partly because the screens are so badly designed.

15, 15 questions instead of one drop down list of the 15 options from which you can choose one. And also, people who aren’t computer literate should be able to put stuff in by writing, phoning, going to see the boss, whatever. So it’s very restricted to the computer. And then the investigation has never seemed to work.

Changes didn’t happen. And sometimes two years later, you’d had no outcome from reporting something serious. So it simply didn’t work. I think what it’s trying to replace. What’s the old system of ward sister, matron, consultants medical director weekly meetings, communications, raising issues, and then getting smart people from management to come and try and help sort things out.

And somehow it just became far too bureaucratic and it didn’t encourage action. During coronavirus, when we had critical incident reviews, I often found that the staff had already put solutions into the problem, which had happened in the morning, but they put in solutions by afternoon.

It was action based, and Datix seems to defer action and just doesn’t achieve anything. It’s, so I was very, quite cynical about it. It should work. I know in Calgary, in Canada, they had a Datix, which they Datix all said you can make it bespoke, and their system pretty much said, who are you? What happened?

And then it went over to the investigation team to do something about it. So I think it, it made it too difficult to report. It distanced the investigators from people who could actually make a difference. And often when the difference Change came back. It was just a new policy, which was sent around by email and you were told to do it rather than a design change Put potassium chloride in the controlled struggle cupboard and don’t let anybody have it unless They really need it.

[00:13:47] Mat: It’s interesting if I think So I have seen Datix work really well, and in my, where I’ve seen it work really well has been in, in repeatedly highlighting sort of a series of, for us it was staff shortages. Yeah. So it wasn’t about, Dr. Caldwell didn’t smile at me or Caldwell dropped a cup of tea and didn’t have had it in the lecture hall.

So it wasn’t that kind of stuff. It was this patient needed x and we don’t have the right stuff. This patient needed y and we don’t have the right stuff. So for me, what worked well was repeatedly. Doing an incident form about the same sort of thing relating to our staffing. And then that what happened with that is over a period of time, that built a picture of multiple patients that have not had optimal care.

And actually nobody particularly came to harm, nobody died. It wasn’t about that; it was a whole collection of patients who repeatedly did not have. the kind of care they should have had as a result of our staffing issues. And that then did lead to our staff improvement because, and I think the way that it, the way that certainly the way that my hospital works is, people will you do the sort of risk assessment.

And the incidence forms feed into the risk assessment process, say, okay, where’s the evidence that patients are coming to harm? For me, the incident forms demonstrated that there was evidence and there was a whole series of specifically named patients that were coming to harm as a result of that.

[00:15:12] Gordon: Yeah, I think with, I tended to make sure that I reported. The adverse events or the significant risks without harm. But then most of the work to get things changed happened outside DATICS. From my experience, actually working around the outside of it was the thing that made the difference.


[00:15:31] Mat: absolutely. And DATICS in that case was it was evidence. I also know that at other times. Where sometimes you get feedback, don’t you? Or at least where I work, often I get feedback, but it depends on who it is. So it very much depends on, I think, on who’s investigating and the quality.

And, and I have been lucky that I have had really good people that repeatedly would come up. Equally, I remember sitting clinical governance meeting and we all say oh, but what can you do? It’s a problem, what are you going to do? And I’m thinking. What do you mean? What are we going to do?

It’s a problem. Let’s fix it. So what can you do? And then we moved on and I’m thinking, what? So anyway, I stopped being part of that committee, Gordon, you’re going to be surprised because I thought this is just a waste of time. We just say, Oh, isn’t it awful? And, and then I’m thinking why aren’t we doing something about it?

Which is your point, isn’t it? Let’s fix it.

[00:16:18] Gordon: Yeah, I think. I can move on to examples. One of the examples from my own case was we had a man, I think, in his 70s who had COPD and pneumonia. And he had been successfully treated with intravenous antibiotics for the pneumonia and was looking as if he was well enough to go home.

And when I was talking to him about going home, he said, what’s this in my arm, doctor? And pulled up his sleeve, and there was a cannula. In his arm. Now, the last time he’d had intravenous antibiotics was 72 hours beforehand, and this cannula was clearly infected. So obviously took the cannula out, and then when we got the culture back, he’d got MRSA septicaemia.

Just because we hadn’t removed the cannula at the appropriate time. He had to spend an extra two weeks in hospital. to get the treatment for his MRSA septicaemia. So that was, that clearly to me was an adverse event, which has happened within my team. And I’d been thinking, so reported it on Datix, of course, talked about it to, to people.

I put together a little PowerPoint on the importance of removing cannulas, because I said to this guy, I’ll do everything I can to make sure it doesn’t happen to anybody else. And circulated the PowerPoint around, let’s put the end to cannula site infections. But that. And a number of other factors was beginning to suggest to me that we needed a standardized approach to the review of every patient.

That would cover the headline stuff, which is obviously COPD and pneumonia and that his CRP is down, he’s looking better, he can go home. But should we work through a standard set of things for every patient rather than what I’d done, I think, up to then all my career, which is turn up at the bedside, do what seemed to make sense, assume we’d done it all and walk off.

And I think I was thinking at that stage of something like a postcard that just had a. A list of all the things that we would do. And that eventually worked through. I went to an international forum on quality and safety and very impressed by Toyota approach to organization and control systems.

And when I was letting my junior doctors do the ward rounds. And eventually the F1 did the ward rounds, saw 25 patients with us, two registrars, me and the SHO helping her. And at the end she said, that was great, but I don’t know if I did everything. That was on Monday. So I said nobody’s ever really told me what doing everything on a ward round is before.

So everybody come back on Wednesday and tell me what you think doing everything is. So I had a meeting on Wednesday for half an hour and we put it all into a list. And decided that’s what we’re going to do for every patient. And that was back in 2009, I think. And I never did a ward round without a list like that ever again.

The list changed, the things we’re checking changed, but I could never make, allow myself to go and see a patient without going methodically through things. In the same way when you go shopping, you’ve got a big shopping list, you methodically go through it. That was sold as a ward round checklist. I think it’d be much better as a ward round review process, and certainly what we found in the ensuing 12, 13 years, that we never started a cannula site infection ever again in our team.

We inherited them from other teams, but we never ever had a cannula site infection again. And the whole, we have you check for cannulas, pull up both sleeves, every patient, every time. Because somebody will put one in overnight on a patient who is going home for no reason at all. So this just became standard process.

And what I regard as frontline quality and safety. Now. Because I was training my junior doctors on how to do ward rounds, and we had the medical student, then we had a piece of paper and we went through it. But quite often I’d then, later on, see my junior doctors doing a review of a patient, maybe separately.

And they’d go through everything without the piece of paper. And that’s absolutely fine. They knew, just like when you’re driving a car, mirror, signal, manoeuvre. Dealt with the main stuff. Are you eating and drinking? Are you in pain? Have you got a cannula? Have you got a catheter? How far have you walked today?

Are you on VT prophylaxis? Are we going to stop it? And they just worked through like that. I’m sure that made a difference to The culture of safety and the safety of our patients as well. Now that’s something that every doctor can do. You don’t need to go to DATICS. You don’t need to change the world.

You don’t need to write papers about it. You can decide what you think is important and make sure you do it.

[00:20:56] Mat: It’s interesting. In my mind, when I do a ward round and not that often now because I’ve got a slightly specialized practice, but I always think airway, breathing and bloods.

Yeah. disability and drugs, eating and exercise. So that was my ABCDE of my work. That’s how I used to do it. This is ENT. So airway, of course, is important. And buy and my checklist would have been different to yours because my would be different to yours.

[00:21:23] Gordon: Yeah. Yeah. No, I think when we devised this and tried to speak to it to other people.

This isn’t something you can just make it’s a policy. Everybody’s using the Caldwell checklist. That wasn’t how we went about it ourselves. We decided what was important to ourselves and we owned that and we owned the changes. So I think one of the only things was, I don’t know It might have been made sure that the clerking sheets are filed into the main notes.

After two months, everybody was doing that. So we didn’t need to have that on the checklist any longer. So we could substitute it with something else or take it or just simply take it out. Yeah, I didn’t like the idea of other people selling I didn’t like it being sold as a checklist, even though we put it in our paper ourselves because it’s, what it is a process, and it’s an important process, therefore you need something to make sure that you’ve done the process.

And it’s interesting, in aviation, generally, they don’t have pieces of paper that are ticked off, because it’s all done verbally, it’s all very quick, but they go through it and they make sure it’s done. And the proof that it’s done is you’ve flown the plane and landed safely. And I think what. I was much too bureaucratic about it myself.

And it’s certainly throughout nursing culture, as well as medical culture, you need to have a piece of paper to prove you’ve done it, rather than a standard operating procedure, and just say I followed the standard operating procedure.

[00:22:44] Mat: You mentioned the Toyota approach. What’s the Toyota approach?

[00:22:47] Gordon: I think, to me, the Toyota approach was which is often sold as lean was really going back to Henry Ford’s idea that you shouldn’t exhaust the knack of your workforce.

You should make the work as easy as possible. as easy to do as possible. With Henry Ford, it was to make sure you didn’t get back injuries hauling engine blocks around. These days for us, I think it’s very similar. The thing, the equivalence is intellectual exercise and effort. So if you can cut down the accessory effort that’s involved, then it can free our brains to think.

I don’t know what your hospital IT systems are like. I’ve never worked with a good hospital IT system other than ones I’ve designed myself. And you’re actually, all the brain’s RAM is occupied with controlling the computer. Whereas what we’re trying to do is control the disease in the patient. And so you’re jumping from six or seven different IT systems while somebody’s shouting at you across the room and our brain just gets muddled.

The Toyota approach would be what’s the most important things doctors are doing? We’re making diagnoses, making plans. Deciding on monitoring, reviewing patients, refining the plans. So anything that can free the brain up to do that. So that’s what I’d say would be the Toyota approach. It’s what are you really trying to achieve?

How can you do it whilst maintaining whole human beings who are content at their work and not knackered by the wrong stuff? You can’t help it if you’ve got 30 patients arriving A& E in 12 hours, but you can make the IT system so much easier to use.

[00:24:21] Mat: One of the things that I experienced when covering the strikes was just how much everything is totally dependent on a computer, yeah, because, last time when I was doing that kind of frontline emergency work, most of these systems didn’t exist, you did stuff on paper you wrote on paper and whereas everything depends on the computer.

And the thing that, that really, for me, was bizarre that, There isn’t a computer by every patient. You go and you see a patient and then you walk somewhere away and you sit down and you log in, which is usually five minutes. And then you type what you’ve just discussed. And for me, that’s totally different to how I work in clinic.

Cause you know, in clinic, I’d sit down with the patient and, I write as I go along, maybe that’s because my shorter memory is not very good. Yeah. But so to be, if a patient sort of says is, my, my child is seven years old or my child is eight years old. I won’t remember that information five minutes later.

Yeah. Although some people might but, it’s not how my mind works. Yeah. That my, my short term memory for real fine details or for numbers. Terrible. Yeah. It’s not stopped me being a good doctor. But a system that relies on me taking the history, keeping it in my mind, going somewhere else, and five minutes later, retyping what I’ve just discussed.

Apart from the fact that it takes longer than just doing it as you go along. It introduces an error, and I’ve never really understood why we write everything on the computer, but the computer isn’t by the patient.

[00:25:46] Gordon: And my father was a systems analyst and a programmer on the first commercial computer in the world, BLEO 2.

Huh. And he was very good on systems analysis. And if you look at the James Robertson Justice films, there were eight people standing around the bed with eight pieces of paper and eight pens. So the systems analysis would say, if you’re going to replace that starting point is eight computers.

Yes. And I agree that the other great danger I see with the computers is the screen looks nice. The keyboard looks nice. Therefore, people assume that what’s behind the screen is good. And in Worthing, when I was leaving there, I think I needed eight different IT applications open simultaneously to deal with each patient and alt tab between them, whilst I’m meant to be listening, as you say, meant to be listening to the patient.

I actually designed a system in my outpatients where I prepared all the information the day before the patient came to clinic. Because I was lucky I was doing an exclusive clinic just for me, no other junior doctors, so I knew the patients I was going to see. So I had dual screens and I put onto that the diagnosis, the meds, and I could talk to the patient without writing or typing anything.

And then I could do voice to text dictation as the patient left the room. So the note, the letter was the notes. And actually never wrote anything in the notes at that stage. And then the letter was with the GP by the time the patient had left the room. Now, to me, that is a safe system again. And so far away from what most of the NHS does, where your clinic letter’s going out four weeks later, the GP doesn’t know what’s going on.

You’ve got a result saying that you’ve got a laryngeal cancer or something come through on an MRI and the GP doesn’t even know the person’s been to outpatients. So again, there’s. There are masses to be done in terms of safety and avoiding adverse reactions in the NHS.

[00:27:37] Mat: And it feels to me like there’s two alternative realities, when it comes to it.

Because if you go on LinkedIn or anywhere like that, there’s the reality of the companies and, and maybe some NHS senior people saying it is going to be brilliant, artificial intelligence revolutionize it. These systems are fantastic. And then there’s the other reality, which is what we and I am talking about.

And I think this is much worse in the U. S. In the U. S. studies, they’ve shown that their, electronic health records are the number one cause of burnout for physicians out there. and deal with that. And yeah it feels like maybe so much of the world at the moment, there’s two parallel realities, isn’t it?

There’s the reality that computer is God and computer is going to fix everything. Maybe like the horizon scandal. And then there’s the reality that you and I are discussing, which is. Which is a kind of say, okay, it’s all very well and your point that instead of making diagnosis, listening to patients, communicating, making decisions, instead of doing that, our brain power is being taken up with navigators and multi-processing.

[00:28:40] Gordon: And that reminded me of another aspect of this safety thing, which is, because you mentioned about America being worse, for me, if I had a patient in Oban hospital who was a tourist from America, it was generally much easier to look after them than a tourist from England. Because they could link on to my hotspot on my mobile phone and get into their electronic records in America.

Okay. So I had a patient who had valvular heart disease and you could actually see the echocardiogram on their mobile phone. and know who’d reported it and know who their specialist was. So to me, one of the ways I hope that things are going to change in your career and the junior doctor’s training now is that patients have full access to their own records and that it’s presented to them in a way that’s navigable so that they can show it to a healthcare professional anywhere in the world.

[00:29:30] Mat: That would be transformational, wouldn’t it?

[00:29:32] Gordon: Yes, yeah, I remember having a, I was lucky enough to be try Don Berwick, in my car for three hours, world leader in patient safety, and he agreed that the biggest step forward in patient safety would be for patients to access, be able to access C and share their medical records with other clinicians.

Because then, you don’t need to go through what are the 10 drugs you’re taking. Because they can show you. Here they are.

[00:30:01] Mat: Absolutely. What else can frontline doctors do in patient safety?

[00:30:08] Gordon: I was just trying to think of all the different things that we’ve had. A different story. I had two patients within a fortnight who both had severe anaphylaxis to penicillin antibiotics.

Despite the fact that they knew they were allergic to penicillin, it was documented everywhere in the notes on the prescription chart, and they were wearing a red wristband as well in a hospital that was in Worthing. And the first Again, I said to the first patient, I’m going to do everything I can to make sure this never happens again and try and understand what it is.

And I think that there tends to be a simplistic reaction in the UK. It’s a bad doctor or a bad nurse who’s messed up. Let’s find the bad doctor. Let’s find the bad nurse. But I looked at the red wristband and in Worthing Hospital at that time it just, it was a red wristband. It didn’t say what the agent was that they’re allergic to.

So I asked the junior doctors on my team, what’s a red wristband mean? And some of them thought it was when they’d run out of black wristbands. They didn’t know red meant allergy. Okay. So the signal wasn’t working properly. So I went to the chief executive and the medical director and said, can we write allergic to penicillin?

Can we even write allergic onto the wristband and preferably allergic to penicillin? And they said, no, it’d be a breach of patient confidentiality, which you might be surprised at. But I’ve got a colleague in Poland who tells me it’s even putting the patient’s name on the wristband as a breach of confidentiality in Poland.

Then it happened to the second patient. So I went back and said, no. We’ve got to at least be able to write allergy and what the agent is they’re allergic to. So they conceded then and agreed to that. But that got me into the whole business of positive patient identification. And there are terrible stories of people dying because they’ve been misidentified.

So that was part of our chat. Good morning. Remind me your name. I’m Matt. Okay. Which I think helped us quite a lot again, because we were misidentifying certain patients, I think, but then three years later, I went into a cubicle where there was a member of our staff having intravenous antibiotics for sepsis after chemo, and the nurse tutor was in there teaching a nurse tutor was student, how to give intravenous antibiotics through a central line.

And the patient didn’t have a wristband on. So I said, oh you’re teaching this nurse how to do this, but there isn’t a wristband. There should be a wristband. Oh, no, this is Jane Smith. I said no, the process is meant to be that you’ve got a wristband and you shouldn’t have got this far without doing it.

Can we ask the ward clerk to go and print a wristband? So she came back and it was an allergy wristband. I think that nurses had got into the habit of going to the patient and saying, You’re Matt, your date of birth is such and such. The patient saying yes, and then missing the final cue on the note for the allergy.

I think it’s just going back to this. Have a routine. These things are there because they really matter. I’ve certainly used to invite people to come and observe my ward rounds. I remember I had the director of finance on my ward rounds. First patient we got to, I seemed to be struggling with the consultation.

The junior doctor said, Dr. Caldwell, this isn’t the patient you think it is. Now that was just fairly simple in early on in the communication, but once you get to, you doing an operation is it the correct patient? And if they’re doing, I don’t know, a left nephrectomy and a right nephrectomy, one after the other, have you got the patients correct?

So it’s, it really is getting, drumming into ourselves that we’ve got to have standard processes. We’ve got to adhere to them. They’ve got to become habits. And that will drive safety. There’s so many things that we can do. You mentioned about, handwriting notes. If you’re handwriting notes, make them legible.

And if you think you’ve got, you’re writing eight pages and they’re illegible, I used to say to my juniors, write two pages and make them legible, please. Because that, firstly, I’ll read them and then I’ll be able to see them. Identify yourself. Again, in Worthing, we were still on paper notes then. And it’s common.

That somebody has squiggled signature at the bottom and put bleep 101 or whatever it was. So I got for our junior doctors rubber stamps on a lanyard that they could fit to their waistband and then they could stamp on it. William Smith, GMC number, such and such. And that shows that you’re proud of your work, shows you’re accessible and will encourage people to contact you and say, Oh, I think, you got the wrong dose of whatever it was or did Mrs.

So and so is upset about the way you explained, can you come back? So just making yourself identifiable, make sure that people really know who you are these all contribute to safety.

[00:35:07] Mat: Just going back to the red wristbands I, I actually really, can relate to that because when they first appeared in our trust, I had no idea what it meant.

Yeah. They may well have been an email that has gone round that explains what, yeah. But the problem is that it was probably hidden amongst a thousand other things that comes through that are all irrelevant. That that, that my brain just doesn’t register. Yeah. But as if it says allergy, I would have known what it meant.

Yeah. We just read, I’ve no idea, what does that mean? But if it said allergy on it, I would have known. And actually, what’s a great. If you talk about technology, what a great use for technology. Imagine if everybody had an electronic wristband that sort of that had, the name on it, you press the button and there was the name and there was the allergies, that would be a great use for technology.

Isn’t it that that you could store information actually in the patient’s wristband,

[00:36:00] Gordon: I think, as we talk, obviously things come to mind, I mentioned that I used to get other people to come and watch my ward round. So once we developed the standard process and the checklist, we probably had 60 or 80.

Professionals, doctors and from outside medicine coming in and I think allowing ourselves to be seen in the workplace is important because if there’s from outside medicine, they often have radical new ideas about how to do things. They can also see how awful and difficult dreadful things are as well, and they can see how important it is to change.

I think that in Worthing, there’ll be a long debate about electronic prescribing and was it worth investing in and I took our chairman down to, the first patient on my ward round and gave him a checklist to work through on the prescription chart, because we also had a checklist for checking the prescription chart.

We’re halfway through one patient’s prescription chart, and he said, we need electronic prescribing. And he went off and more or less commissioned it. So all, as you said, I think we’ve touched on it, all this talk and the bureaucracy doesn’t match people coming to the workplace and seeing what we do and seeing if they can help.

I had. a particularly good head of IT just before I left, and he came on my ward rounds, then he sent his team on our ward rounds, and within four weeks we had a new piece of software that ran our ward rounds. It was great. The big IT seems to fail so often. The electronic prescribing they put in, if you entered that the patient was allergic to penicillin, you could still prescribe the patient Augmentin.

Okay. What’s the point? Yeah. Yeah, and it’s another bad adverse reaction in the same trust where a patient was killed with a ten times overdose of intravenous digoxin. And the, then the medical director at the time said that the solution was electronic prescribing. The electronic prescribing they had no way to put a maximum dose onto any medication.

So it didn’t solve the problem at all. So again, us talking about these things, reporting them, not accepting them and often the response I got was that’s the way it is, you’ve just got to be careful. Going back to your point about design, that’s bad design. You’ve got to have something that makes it so easy for people to get it right, difficult to get it wrong.

You don’t have to be constantly reminding them. And at the same time, the electronic prescribing was flagging up hundreds of potential adverse reactions of no significance at all. So to get anything prescribed, you had to click off, I’m not bothered about that, not bothered about that. But you could still do the most dangerous thing, which is overdose a patient to a medicine they’re allergic to.

[00:38:36] Mat: Gordon, you mentioned that that we’ve got we shouldn’t stand for it. We should keep fighting, we should challenge, but where, you’ve retired now and there’s an awful lot of doctors that that I talk to and there’s a fair bit of apathy, I think, and people are almost given up.

So where does your energy to keep going on about this kind of stuff come from?

[00:38:56] Gordon: I think the energy, I think, ultimately came from the patient. And however dreadful the situations are, I think we can still connect with our patients and if we lose that connection, that’s serious. We’re losing connection, we need the connection with our patients and connection with our colleagues.

Now, all patients that I consulted with, unless they’re unconscious I used to start, always remind me how old you are, what is or was your occupation, what are you interested in, what do you enjoy these days. So even somebody coming in with a heart attack, get that connection, know who the person is. So then I’m dealing with somebody who’s a real person, and I want to get them better.

And that’s what motivated us, most of us, to go into medicine in the UK. So that connection, remember that connection. The occupational history used to be on page six of the Cambridge, Harvard, whatever it was, model of clinical clerking. I always put it right number one. Apart from that, they also just gets the patient speaking.

And then the connection with our colleagues is unfortunate, but I think my generation of doctors are allowed to be surrendered. The fact that we don’t have a weekly grand round. That we don’t have weekly departmental meetings. We don’t have journal clubs. We don’t sit down and eat lunch together.

Those, that to me was where a whole lot of that energy for change came from, was connecting with other people. And if one person goes to IT and says, there’s no limit on the maximum drug, they can just say go away. It doesn’t matter. If a hundred people go and say it, they should, obviously we know from the post office scandal, they don’t necessarily listen, but I think, yeah, I think it’s much more like in the health service.

If you had a hundred people going along saying this there’s a chance, but we’ve been disempowered because we don’t speak to each other. We don’t know each other. The collegiate structure’s gone. And I think there is the potential that we could fight back on that. I think the colleges should be fighting back on it.

The union should be fighting back on it. The deaneries should be fighting back on it. The deaneries, I think, have been lamentable in the way that they’ve allowed that collegiate structure within hospitals to go, because so much of teaching and training depends on it.

[00:41:12] Mat: Okay, and then maybe my final question, when it comes to dealing with adverse health care events, what would be your top tips for doctors at work?

[00:41:21] Gordon: I think the first thing is to talk about it and report it through whatever system it is, in whatever brief format you can. And then to stand back and think, what could I do? Is there something I can do within my own working? environment that doesn’t require investment and major change.

Something that I can do that can tighten up on this and improve on that. So the two patients I had with anaphylaxis, we decided we’re going to look at the wristband every patient every day and make sure it was fine. And the early days, actually, we found 10 percent of patients didn’t have wristbands at all.

What can you do yourself? And to me, a whole lot of what can we do ourselves is being structured, methodical, organized, and making sure we’ve done it.

[00:42:07] Mat: Wonderful. Thank you very much, Gordon.

Share the knowledge

If you have any questions about anything in this article or about coaching, please don’t hesitate toget in touch.