The Society's Fifith Annual Lecture by Sir Liam Donaldson

The Lunar Society's  Fifth Annual Lecture by Professor Sir Liam Donaldson CMO  The Challenges for Medicine in the 21st Century  was delivered to a capacity audience in  the Leonard Deacon Theatre at the Medical School in the University of Birmingham on 5 March 2008.

Click here to read the review of Sir Liam's Lecture in the Birmingham Post.

Below is summary of his Lecture by the CMO office:

The Lecture presented a series of patients who were harmed by medical error. Errors in hospital are common. When errors occur, it is easy to try to blame one person. If we are to understand why errors occur and to develop ways to prevent them from happening in the future, we need to understand that errors happen because of failings of systems rather than individuals.

One model that can be used to explain how errors occur is James Reason's Swiss Cheese model. This shows that a successive layer of defences, barriers and safeguards exist which prevent errors from occurring. In each of these layers there are holes, as in a Swiss cheese. Error occurs when each of these layers are positioned so that the holes line up and a chain of events allows an error to slip through each of these protective layers.

Catastrophic events occur in other industries. Healthcare has a great deal to learn from them. Safety in the aviation industry was highlighted by the BA crash at Heathrow earlier this year. All 136 passengers and 16 crew on the flight survived. The commercial pilot at the controls had had many years of continuing training in simulators throughout his career. He had practiced emergency situations many times, and been assessed to ensure that his performance is good enough.

His experience in simulators is very different from that of British doctors. Once in independent practice, doctors are not formally assessed until retirement. Over an equivalent period, a commercial pilot would be subject to around 100 formal, objective assessment of their competence. Some innovators already use sophisticated equivalent to train medical staff. Simulation exercises have made a difference to the technical skill of doctors. We have the potential to harness these new technologies and bring them into the mainstream to benefit our healthcare professionals and our patients.

If we are to make care safer as we move further into the 21st centgury, we need to ensure that healthcare professionals are adequately training to do their jobs. We need to ensure that systems are developed which act to identify, understand and reduce risk. And we need strong and committed political, clinical and managerial leadership to ensure that a culture of patient safety flourishes in our hospitals. Above all, we must remember that patients are at the centre of what we do as healthcare professionals. We must ensure that the safety of patients in our care is given the highest priority in every aspect of the healthcare system.