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Improving patient safety in paediatrics and child health
  1. Terence Stephenson
  1. Professor Terence Stephenson, Academic Division of Child Health, School of Human Development, Nottingham University, Queen’s Medical Centre, Nottingham NG7 2UH, UK; terence.stephenson{at}nottingham.ac.uk

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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.

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Table 1 Recent National Patient Safety Agency initiatives aimed at the safety of children

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 …

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