|Job Title:||Professor of Cardiothoracic Surgery UCL, Professor of Physic at Gresham College|
|Title of talk:||Learning from our Mistakes|
|Biographical Sketch:||I have been a consultant at GOSH since 1985, and hold the academic and teaching roles above. I have led many teams and was clinical director of a large division before becoming medical Director of GOSH from 2010 til 2015. I led the Quality and Safety team.
I have held and do hold several international visiting professorships, am widely published. I teach on the cabinet office leadership course, work with the Whitehall Industry Group and have advised health systems throughout the world. I work with many companies to improve teamwork and quality reporting. I am Chief Medical Officer of a Software company.
I am obsessed by the need for transparency in outcomes (working with international registries), and honesty in the reporting of error.
My research has covered the pathophysiology of bypass, near infrared spectroscopy, outcomes analysis, and most recently tracheal transplantation.
|Lecture Abstract:||The safety of the patient is paramount. Human error is normal. The NHS is labour intensive, and the number of interfaces between individuals and teams is huge. All these interfaces can fail.
In this lecture, I will explain these theoretical points and indicate how a transparent approach to outcome reporting, in real time, can influence behaviour for the better, trading on our competitive instincts.
I will also examine the negative consequences of blame, and discuss how organisations and units can encourage a just culture in which learning from error is the norm.
I will use real examples where appropriate and suggest methods which will work in any speciality