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Leading articles |
1 The University of Nottingham, United Kingdom
* To whom correspondence should be addressed. E-mail: terence.stephenson{at}nottingham.ac.uk.
Accepted 5 March 2008
| Abstract |
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In 2005, I wrote about the new UK National Patient Safety Agency (NPSA) [1]. However, patient safety is about much more than a government agency; it is about a huge cultural change in how doctors practise.
Two anecdotal case studies may be of interest. In October 2007 the US Department of Justice fined British Petroleum $50m relating to the Texas City refinery explosion in 2005 which killed 15 people and injured 170.
In November 2006 I spent a week with the oil company Shell on an attachment organised by the National School of Government. I wanted exposure to an industrial environment where, like paediatrics, safety is crucial and where things can go wrong very quickly. I retain three memorable images from my arrival at Shell, none of which were the 'rocket science' I anticipated of the high-tech petroleum industry.
The car from the airport could park at Shell only by reversing into the parking space - accidents happen when drivers reverse out after work in the evening darkness. On entering the building and climbing the stairs, I was politely told I had to hold the stair rail. This behaviour would not come as second nature on a North Sea oil rig if not insisted upon ashore. My cup of coffee had to be covered with a lid if I wanted to carry it around the office with me.
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