Dr Peter Moore: We owe it to the next generation to learn from Coronavirus pandemic
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In Gilbert and Sullivan's Mikado, three of the main characters have to persuade the emperor they have carried out an execution and so they invent one in graphic detail.
They all claim to be the hero of the action.
Unfortunately, the person they 'executed' turns out to be the emperor's son. The moment the emperor sees his son's name on the certificate the three backpedal. 'We had no idea', 'I knew nothing about it' and, best of all, 'I wasn't there'.
Although written 135 years ago, Gilbert knew human nature. We all like to claim credit for success but, if there's a problem: 'I knew nothing about it' or 'I wasn't there'.
Unfortunately, this approach prevents us from learning from our mistakes.
GPs may see more than 150 patients a week, check hundreds of pathology and X-ray results and sign numerous forms, prescriptions and letters.
It is impossible to prevent every error but we can put systems in place to ensure that if anything goes wrong there are checks and balances to ensure no harm is done.
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In the NHS we ran 'significant event meetings'. As with many other good ideas the concept was nicked from the airline industry. They accept pilots will make mistakes. They are human. But there are systems in place to ensure that getting things wrong does not end in disaster. And they are very successful with air travel one of the safest method of transport.
In our 'significant event meetings' any member of the team could present a case. It could be a near disaster or some minor issue, but there were firm rules.
The person presenting would simply outline the facts. They would then have an opportunity to explain what went well and where things could be improved.
Everyone had to be supportive with no culture of blame; no points scoring; just what went wrong with the system and how we can improve.
These meetings would only work if people were honest and they would only be honest if they knew they would not be blamed or made to feel guilty.
At the end of the meetings changes were agreed to prevent the issue from happening again or a 'safety net' to ensure that if it did happen no harm was done.
The meetings worked because I knew every member of our team.
I knew that they were all highly competent and caring. Any problem was neither deliberate nor due to malice.
When things do go wrong it is important to stand back and look at the whole problem rather than blame someone.
If a junior doctor makes a mistake, we should ask 'did the doctor have enough support?', 'were they trained for the task?' or 'was a senior doctor available to contact for help and advice?'
We will not learn and prevent future problems by creating a scapegoat.
Perhaps I am being naive but shouldn't we take this approach when we look back on the coronavirus crisis?
Questions must be asked.
Why was there a shortage of personal protective equipment or testing? Was the lockdown too late? Why has Germany been so much more effective?
It is too early to draw conclusions but it looks as though we will be among the most affected developed countries.
Despite the cut and thrust of politics the vast majority of politicians are decent caring people trying to help.
I may passionately disagree with a politician but I know that they are neither stupid nor evil.
Is it asking too much to hope that, when we look back, everyone involved will openly discuss what went well and what did not without the Government spinning the figures or opposition parties trying to score political points?
One day there will be another pandemic.
We owe it to the next generation to learn from this crisis.
No-one should say 'we had no idea', 'I knew nothing about it' or 'I wasn't there'.