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Improving patient safety in paediatrics and child health
  1. Terence Stephenson (terence.stephenson{at}nottingham.ac.uk)
  1. The University of Nottingham, United Kingdom

    Abstract

    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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