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The Patient Safety Academy (PSA) at the Nuffield Department of Surgical Sciences was honoured to host two high profile British doctors and an international research leader yesterday.

Front row, from L-R: Lord Ribeiro, Professor Peter McCulloch, Dr Helen Higham, Dame Clare Marx. Back row, from L-R: Dr Dawn Benson, Mrs Janet Higham, Dr Baptiste Vasey, Dr Neale Marlow, Dr Joanne Kitchin, Professor Salome Maswime, Dr Rajh Kumar, Dr Peyton Davies.

Dame Clare Marx, previously a Consultant Orthopaedic surgeon, is Chair of the General Medical Council (GMC), the body which regulates UK doctors. Lord Ribeiro, who was born in Ghana, is a retired general surgeon, was the first black president of the Royal College of Surgeons, and is a strong supporter of efforts to strengthen surgery in low income countries.

They attended a seminar to learn about the PSA’s use of Human Factors science to improve patient safety together with Professor Salome Maswime, the Professor of Global Surgery at the University of Cape Town, South Africa.

The visit of these prominent guests recognises the leading role the PSA is playing in developing practical solutions to make healthcare safer in the UK and internationally.

Members of the PSA, which is hosted by the Medical Science Division of Oxford University and directed by Professor Peter McCulloch and Dr Helen Higham, explained how the team are currently using Human Factors to help the GMC improve their investigation methods when concerns are raised about doctors’ fitness to practice, and to improve surgical teamwork and reduce risks for African mothers undergoing caesarean section deliveries.

Human Factors

The PSA provides training, conducts research and supports improvement projects using Human Factors to make patient care safer and reduce errors in care. Human Factors is a scientific discipline which studies how people, technology and work systems interact, and develops ways of improving quality, safety and efficiency. This is very important in safety critical environments, such as modern high-tech medical care, where the complexity of the system increases the risk of error. Over the last six years the PSA has made important advances in understanding how to reduce risks to patients, and especially in how to investigate incidents where things have gone wrong. 

The PSA’s approach to analysing the context, so as to help understand the factors and pressures which can lead to mistakes by clinical staff, has attracted the attention of the GMC, which is seeking to improve its systems for investigating doctors whose fitness to practice is in question. The PSA and the GMC are now working in partnership on a programme of training and process redesign at the GMC to help achieve this. Dame Clare has recently taken over as the first female Chair of the GMC, having formerly also been the first female President of the Royal College of Surgeons. 

We were delighted by the recognition this visit gives to the importance of the work of the PSA nationally and internationally - Professor Peter McCulloch

Lord Ribeiro preceded Dame Clare at the Royal College of Surgeons. He has a great interest in global surgery, which seeks to improve access to and quality of surgery in less developed countries.

Another aspect of the PSA’s work is with partners at the University of Cape Town on projects to use Human Factors to improve the safety of surgery in lower income countries, and Dr Maswime attended the meeting to discuss this with PSA leaders.

Later on in the day, the guests had an opportunity to see simulation training for clinical staff in dealing with emergency situations in the OxSTaR (Oxford Simulation, Teaching and Research) medical simulation suite, and were able to discuss with Dr Higham, who is the Director of OxSTaR, the potential benefits for patients of the two ongoing projects.

Dr Higham commented: “The visit of Dame Clare Marx and Lord Ribeiro provided us with opportunity to showcase the Patient Safety Academy’s work on embedding human factors training for healthcare professionals in Thames Valley and in particular our work on incident analysis training. We were able to highlight the value of simulation for learning from critical incidents by observing some excellent multidisciplinary scenarios for staff in our Emergency Department - clear evidence that the partnership between NDS, Nuffield Department of Clinical Neurosciences and the Oxford University Hospitals NHS Foundation Trust is supporting safer patient care in Oxford.”

Professor McCulloch said: “We were delighted by the recognition this visit gives to the importance of the work of the PSA nationally and internationally."

Professor Maswime said: "It was great being part of this meeting and learning about human factors, simulation and patient safety."

Media coverage

BBC South Today, 5 September 2019

Professor Peter McCulloch, Dr Helen Higham and Lord Ribeiro were interviewed about improving patient safety, the work of the PSA, and the simulation training in OxSTaR. 

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