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In 2005, I wrote about the new UK National Patient Safety Agency (NPSA).1 Table 1 lists some NPSA initiatives relevant to children introduced since then. However, patient safety is about much more than a government agency – it is about a huge cultural change in how doctors practise. Two case studies highlight some of the issues.
In October 2007 the US Department of Justice fined British Petroleum US$50 million relating to the 2005 Texas City refinery explosion which killed 15 people and injured 170. In November 2006 I spent a week with the oil company Shell, 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 depended on the “rocket science” 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 in the evening darkness after work. On entering the building and climbing the stairs, I was politely told I had to hold the hand rail. This behaviour would not come as second nature on a North Sea oil rig if not insisted upon ashore. And my hot drink had to be covered with a lid if I wanted to carry it around the office with me.
Here seemed to be an organisation imbued with a deeply entrenched safety culture, running through every aspect of its work. In their view, there were two ways of doing something – “the Shell way” and “the wrong way”. Some say that such an approach stifles initiative and creativity, but the correct place for these virtues lies in well conducted, controlled research …