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National Patient Safety Agency

Updated guide places junior doctors at centre of strong safety culture

8 July 2010

An updated guide has been published by the National Patient Safety Agency (NPSA) which describes steps junior doctors should follow in the event of a medical safety incident.


Medical Error: What to do if things go wrong describes the importance of effective communication, documentation, reporting and complaint handling by junior doctors following a medical error and includes case studies based on previous real life situations.


It also highlights:

• the common sources of errors for junior doctors, such as handover and documentation;
• the importance of Being open* when mistakes happen and how to deal with complaints;
• advice and experience from key stakeholders such as senior doctors, Medical Defence Union and Medical Protection Society.


NPSA’s Medical Director, Dr Kevin Cleary, said: “Engaging with junior doctors has led to a rise in reporting while embedding a strong patient safety culture among all NHS staff.


“This updated guide reflects the increased levels of transparency within the NHS and develops the role junior doctors can play to increase safety for patients.  They may be in the best position to see how changes can make a real difference to the safety of patients.”


NPSA’s Chairman Professor Sir Liam Donaldson said: “Junior doctors are the future of the NHS, and it is vital that they lead and influence this open and transparent culture. They are the generation of healthcare professionals that can embed change and protect the safety of patients.”


Chief Medical Officer for Wales, Dr Tony Jewell, added: “Patient safety is the top priority for the NHS. This guidance reiterates the importance of reporting all incidents or potential incidents that could have an impact on patient care. This ensures we continually learn and reduce risk to patients. This is in line with our 1,000 Lives Plus programme which aims to improve patients safety and our Putting Things Right work on listening to patients and addressing their concerns about care.”


A copy of Medical Error: What to do if things go wrong is available at: http://www.nrls.npsa.nhs.uk/juniordoctors



Notes to editors:

1. Media enquiries to the NPSA Press Office:

Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk

Dominic Stevenson – 020 7927 9351 / dominic.stevenson@npsa.nhs.uk


Out of hours – 0788 411 5956


2. The National Patient Safety Agency (NPSA) is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, Patient Safety and the National Clinical Assessment Service. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.nrls.npsa.nhs.uk.


3.  * Being open involves:
• acknowledging, apologising and explaining when things go wrong;
• conducting a thorough investigation into incidents and reassuring patients, their families and carers that lessons learned will help prevent incidents recurring;
• providing support for those involved to cope with the physical and psychological consequences of what happened.