What to do if things go wrong: a guide for junior doctors

This National Patient Safety Agency's booklet is a guide for junior doctors to manage a patient safety incident.

It is organized in 6 sections.

First, a description of a personal experience of having a medical incident. Second, to document the incident in the patient’s medical records and to inform consultant and/or supervisor. Third, to communicate the incident to the patient, family and caregivers and apologise to all. Fourth, to report the incident in a local reporting system. Fifth, the guide enhance that junior doctors, on the frontline of care, are vital in the identification of learning from reporting. Finally, an algorithm is presented to deal with the complaints process in England.

Every section is introduced by an incident description from a relevant medical doctor in England.

It is easy to read and a good example to adapt in every country as a guide to promote good answers to incidents in practice for junior doctors.

Medical error. What to do if things go wrong: a guide for junior doctors


Posted by Pilar Astier
English version by Pilar Astier

The quality, security and content of telephone and face-to-face consultations: a comparative study

Telephone consulting is increasingly used to improve access to care and optimise resources. However, there remains a debate about how such consultations differ from face-to-face consultations in terms of content, quality and safety. To investigate this, a comparison of family doctors' telephone and face-to-face consultations was conducted.

106 audio-recordings, from 19 doctors in nine practices, of telephone and face-to-face consultations, stratified at doctor level, were compared using:

- The Roter Interaction Analysis Scale (RIAS), measuring the content

- The OPTION, that observes patient involvement in decision making

- A modified scale based on the Royal College of General Practitioners (RCGP) consultation assessment instrument, measuring quality and safety

- Patient satisfaction and training (empowerment) were measured using validated instruments.

Telephone consultations were shorter: 4.6 minutes, on average, compared to 9.7 minutes of the face-to-face ones.

The study concludes that although telephone consultations are convenient and judged satisfactory by patients and doctors, they may compromise patient safety more than face-to-face consultations and further research is required to elucidate this.

Telephone consultations are more suited to follow-up and management of chronic diseases than for acute management.

McKinstry B, Hammersley V, Burton C, Pinnock H, Elton R, Dowell J, et al. The quality, safety and content of telephone and face-to-face Consultations: a comparative study. Qual Saf Health Care. 2010 Aug; 19 (4) :298-303.


Posted by Lola Martín
English version by Erika Céspedes

Interview with Miguel Angel Máñez. Can we sell better the safety culture?

We met Miguel Angel Máñez at the Security Master developed by the Spanish Ministry of Health and Social Policy and the Miguel Hernández University. We felt he provided a new –and very necessary- point of view respecting safety culture. That is why we asked to interview him and he has kindly answered.

Miguel Angel Máñez is an economist. He is currently the Deputy Manager of Economic and Human resources of the Alicante-Sant Joan Health Department. He is the author of Salud con Cosas, a blog on healthcare management, since 2007. His areas of interest are leadership and clinical governance, innovation, social marketing applied to healthcare organizations, health 2.0 and change management. He has participated in courses and seminars on Internet and health, healthcare management and marketing; and he has also written articles in various media on these topics.

- S & H: Why, if we all agree on the "primun non nocere", in the ethical principle of nonmaleficence, are there difficulties for health professionals to take on the problems on patient safety?

- M. A. M.: The custom and culture of each organization play an important role in how professionals behave. To generate a behaviour change is complex in humans and that is why incentives or rewards are often used to make this change not only fast but also durable. However, in the healthcare environment, the incentives associated with the implementation of a new culture based on patient safety are not very effective (in the case of economic incentives) and difficult to apply (the non-economic).

A clear comparison is the behaviour change in business environment, since to get a consumer buy a product is to create a purchase impulse that can produce positive results in just three minutes, but to change behaviour is something very long.

Finally, in the case of patient safety, the benefits are invisible to the professional, as they directly affect third parties, making the change difficult.

And counting on it, from your point of view, what are the strategies to succeed in introducing this culture? How can we “sell” it?

First, we must show that there is a direct benefit for the professional. Without demonstrating that the change creates value for both professionals and their activities, we can not move forward. Social marketing techniques seek to modify behaviour based on an exchange, analyzing the attitudes of members of the organization to the proposed behaviour, and providing each professional skills and motivation both necessary to understand he can make that change.

We have to dissociate the "sale" of that culture of the monetary concept of the term "sale." Economic incentives only work in the short-run and, indeed, any change brought whit an economic incentive disappears when the incentive disappears. The design of incentives should be conducted in a manner that achieves a long-term change, appealing to professional values, beliefs and their abilities to overcome obstacles.

Moreover, a new culture implies that we must know exactly how the professionals of the organization are in order to detect the leaders, innovators and "early adopters" (in Rogers’s terminology) who are going to serve as engine and example. In addition, managers must act according to the new culture, to keep the professional look at their own bosses trying to implement a new way of doing things that they do not follow.

Finally, we need a consistent and innovative training base: workshops in the workplace, courses, training for managers of each unit, reminders, etc. Any support material is welcome, but also the originality and innovation will be appreciated to reach the professional’s attention.

Finally, what role do patients play in this topic?

The patient plays a central role, because if healthcare organizations seek to generate a cultural change aimed at the improvement in security, is because it has been shown that there is improvement in patient care: more quality, more safety. Perhaps we have gone through a culture of wellness and safety time for the professional, sometimes forgetting, in the process design, that the ultimate objective of health services is to provide a range of patient cares.

One way that lately has been used to achieve these changes in the culture we are discussing is to use the patient as a means of transmitting the professional the need to make things differently. Within the National Health Service (NHS) it has been much criticized, as there are professionals very reluctant to the idea of a patient requiring them to perform a task one way or another, but it is usually very effective. In fact, we are conducting in our center a project in social marketing and hand washing aimed to relate each type of marketing strategy with a change in professional’s behaviour.

Thank you very much for talking to us. Now it is time to reflect on what we have expressed and to work, more focused, to keep trying to create that culture of safety.

Thank you very much


+ Info: a very interesting link, his class in the Patient Safety Master of the Spanish Ministry of Health and Social Policy and the Miguel Hernández University, where Miguel Angel Máñez develops some of the ideas reviewed in the interview.


Posted by Safe and Healthy
English version by Erika Céspedes

Atención Primaria Editorial: semFYC adapts the WHO recommendations on hand hygiene for Primary Care

The journal Atención Primaria publishes in its last number an editorial with the title: La Sociedad Española de Medicina Familiar y Comunitaria adapta las recomendaciones sobre higiene de las manos de la Organización Mundial de la Salud para atención primaria (The Spanish Society of Family and Community Medicine adapts the World Health Organization recommendations on hand hygiene for Primary Care).

The editorial is about why and how the semFYC’s Patient Safety Group, which manages this blog, made recommendations on that subject as well as a summary of its contents.

The full text of the Recommendations on hand hygiene for Primary Health Care workers and for Health Services in Spain can be downloaded here (html) and here (pdf)


Palacio J, Aibar C, Marec R. La Sociedad Española de Medicina Familiar y Comunitaria adapta las recomendaciones sobre higiene de las manos de la Organización Mundial de la Salud para atención primaria (The Spanish Society of Family and Community Medicine recommendations on adapting the hand hygiene of the World Health Organization for Primary Care). Aten Primaria. 2010; 42:401-2.


Posted by Safe and Healthy
English version by Erika Céspedes

3rd Seminar. Assessment of the observance of Hand Hygiene in a Primary Care area of Madrid

With the aim of bringing good practices to our daily work, we start a little series where we will bring to the blog the oral communications presented at the last 3rd Seminar for the Improvement of Patient Safety in Primary Care.

And we start with a polemical topic, hand hygiene.

We know that hand hygiene, as the WHO recommends, is a controversial topic in Primary Care, where the famous five stages do not find a proper insertion. To approximate us to reality the Training and Research Unit of the 4th Area of Madrid designed an observational study whose results were presented at the Seminar. Those results are very interesting because they show a low level of observance, even after risk of exposure to body fluids. Although the WHO recommendations are not enterely applicable in Primary Care, this study provides evidence that our reality, on hand hygiene, may be well below than acceptable. Both at Hospitals and Primary Care, it seems to be great opportunities to improve a behaviour that affects patient and professional safety.

The researchers have been Carmen Martín Madrazo, Juan Carlos Abanades Herranz, Asunción Cañada Dorado, Miguel Salinero Fort and Sonia Soto Diaz.

+ Info: Summary of the Communication Evaluación del cumplimiento de higiene de manos en un Área de Atención Primaria de Madrid (Assessment of the observance of Hand Hygiene in a Primary Care area of Madrid)

See also in this blog: Recomendaciones sobre higiene de las manos en Atención Primaria (Recommendations on Hand Hygiene in Primary Care)


Posted by Fernando Palacio
English version by Erika Céspedes

Manual of Patient Safety for nursing

Nurses play a vital role in improving the safety and quality of patient care, not only in health care facilities but also community-based care and the care performed by family members. That is why we echo a publication of 2008 of the Agency for Healthcare Research and Quality (AHQR) that may be useful for nurses to select techniques and interventions with proven effecacy.

The publication of 1 400 pages, is titled Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

It is structured in the following sections:

- Patient Safety and Quality
- Evidence-Based Practice
- Patient-Centered Care
- Work Conditions and Work Environment
- Critical Opportunities for Patient Safety and Quality
- Tools

It is a complete, clear, scientific and practical book.

Hughes RG (ed.). Patient safety and quality: An evidence-based handbook for nurses. (Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality, March 2008.


Contribution by Jesús Moreno, a nurse. Entrimo Health Center (Terrachan), Spain.
English version by Erika Céspedes

V International Conference on Patient Safety

Under the Spanish Presidency of the U.E. Madrid was held at the V International Conference on Patient Safety. Impeccable organization and excellent speakers at tables rather moderate.

A lot and very good. How to summarize? I chose to reflect what has impressed me most as a family doctor who has left these days its small and saturated query to continue learning to improve the safety of care patients receive.

I encourage the rest of the attendees to write their impressions on this blog from the same or from other points of view and thereby enrich my comment.

About infections associated with health care and antimicrobial resistance I noted: Over 50% of the Spanish adult population admitted having taken antibiotics in the last year (30% "with the flu").

Antibiotic consumption is associated with increased bacterial resistance which cause delays in the administration of effective treatments and therefore increase morbidity and mortality, prolonged hospital stay and high economic costs. Resistance increases with increased use. It is shown that less use increase complications in patients with infectious disease.
In Spain, 92% of antibiotics are acquired by prescription (in France 97%, with a European average of 95%).

Other data for comparison with the rest of Europe: we consume more broad-spectrum antibiotics and continues the upward trend in the prevalence of MRSA in our hospitals (the French show that this trend can be reversed).

Research on antibiotic therapy is virtually idle since the 60s (currently only a research compound against gram negative).

There is decrease in the supply of active ingredients while raising presentations. The EFG represent 43% of prescriptions.

What I can do?

Non-pharmacological interventions:

Prudent use of antibiotics: only when necessary, correct intervals and duration.

Optimization of empirical treatments. Prescribing based on evidence.

Help end the illegal practice of giving antibiotics without a prescription at the pharmacy (for example, not providing the same into the patient).

Ask to enhance research in antibiotics (eg, not favoring my requirements that the business is in selling so many drugs that do not represent steps)

Find information and training and quality transparent

Collaborate with health authorities in health education campaigns for proper use of antibiotics and other initiatives related to patient safety.

Regarding measures to be taken to prevent transmission of pathogens themselves that we use and abuse the most powerful tool to address infections associated with health care: hand hygiene. Compliance through this simple but effective measure is only 38% and fewer doctors that nurses meet.

I keep taking note of the representatives of our patients tell us they are in health care silence and concealment of errors, reactive actions to prevail against those aimed at preventing them.

We ask for proactive risk management, teamwork, improve communication with and among us, standardization of procedures based on best available knowledge to care "partnerships" with industry to establish and therefore we do not focus on the sophisticated technology in the pursuit of our interest but in the promotion of good practice and in them, our patients.

They in turn are considering what to do for health systems and better use of resources and effort to ask for and offer honesty, transparency and participation.

Already in the last speech heartened to hear that primary care matters a great deal, how to tell us so little!

But beyond the first moment of pride that we have to take rather this phrase as a warning: be so important in AP extent of the risk does not appear to be reaching for now strategies to achieve safer health care in the same So get to other levels of care.

I recommend to visit the website of the Linneaus project.

For my part I try, and this week in my small and saturated consultation, follow some concrete recommendations for action by his representative: Do not lose sight of the importance of good interaction with the patient to understand and follow my explanations, explanations should be improving day by day and manage my time so you can establish routines that allow me to advance the consultation of the patient if something can not go well and record, report, analyze and learn from the failures and errors.


Posted by Marian López Orive
English version by Jesús Moreno

From Evidence-based Medicine to Marketing-based Medicine

A study published in the Journal of Bioethical Inquiry shows how pharmaceutical companies use business marketing strategies that serve to provide very flattering data, with respect to its products, in terms of efficacy and safety. In this way they get to influence the opinion of prescribers and clearly enhance their marketing interests.

The study uses several internal documents from the pharmaceutical industry and analyzes which strategies are used. Some of the most significant are the Suppression and spinning of negative data and the publication of their studies in journals of high reputation, using the name of well-known professionals who lend their names to change counterparts, whereas the real authors of the article corresponds to a 'ghost' hired by the company. The objective of this technique is to get scientific credibility among readers.

The authors present examples of strategies used in the field of mental health by different companies, transforming studies whose results show a lack of efficacy or questionable efficacy in an effective study.

Other strategies used serve to increase the indications for its products, especially in subclinical or borderline situations. It highlights how the industry segments the market according to the personal profile of the physicians, directing their efforts mainly towards those profiles that are more easily influenced.

The authors conclude that the impact of marketing-based medicine is a poorer health outcomes and increased costs, making it necessary to propose solutions that enable a transparent dissemination of studies conducted by pharmaceutical companies. Those solutions are the prospective registry of clinical trials and their results in public acces registries, public access to regulatory agency reports, as well as a more rigorous role of the editors of medical journals.

These behaviors are obviously hidden, making it difficult to know its extent. That raises the need to reform the system for development and approval of new treatments to enhance transparency and independence in the assessment of both their effectiveness and safety.

Full text: Spielmans GI, Parry PI. From Evidence-based Medicine to Marketing-based Medicine: Evidence from Internal Industry Documents. Journal of Bioethical Inquiry. 2007; 7:1(13-29)

See also Industria farmaceútica y promoción de medicamentos ¿todo vale?


Posted by Guadalupe Olivera
English version by Erika Céspedes

The nursing organization, access to training and motivation are key to safety in hospitals.

The next day May 21 will be held in Madrid, at the Carlos III Health Institute, the symposium "Nurse staffing and its Impact on Patient Safety: towards a Better forecast of human resources in nursing needs", organized by Investen. During this event will be the study RN4CAST that although referred to hospitals, is worth seeing
for the uniqueness of your starting point: studies of Linda Aiken.

In 2002 and 2003, Aiken released his studies (see links at the bottom) on the so-called "magnetic hospitals,"those who attract the best medical and nursing professionals. They showed that nursing human resources influence the quality of the results of these hospitals, in aspects such as mortality or neglect of patient calls, in addition to its own welfare of nurses. Since then the concern for proper management of nursing resources and the design of planning models needs of these resources has been increasing. It should be noted that the results of Aiken were adjusted for other resources, such as doctor / beds or others.

In this sense, the project is underway Forecasting Registered Nurse (RN4CAST) that aims to collect data from 15,000 nurses and 10,000 patients in 330 hospitals in 11 countries participating in the study. Data are being collected from the environment and human resource nurses through the hospital and the nurses themselves.

These data will be associated with patient outcomes, which will be drawn from the records afterthe high standard of patients.

Data collection will take place in acute general hospitals and in them the majority of working nurses are responsible for the greatest number of medical errors and the biggest share of health spending.

The project is coordinated by the Center for Health Services and Nursing Research of the Katholieke Universiteit Leuven, Belgium, together with the Center for Health Outcomes and Policy Research at the University of Pennsylvania (USA) as vice-coordinator.

Participating countries are Belgium, Finland, Germany, Greece, Ireland, Poland, Spain, Sweden, Switzerland,Netherlands, UK, U.S. and three international cooperation partners (Botswana, China, and South Africa).

In Spain, the project is coordinated by the Instituto de Salud Carlos III, through INVESTEN.

With the results of the project will support the creation of standards for human resource planning in nursing.

It would be interesting that studies be undertaken similar to this one focusing on the area of primary care,which allow us to explore in an objective manner, what is the influence of staffing ratios on patient safety.


Aiken, LH, Clarke SP, Sloane DM, (2002) Hospital staffing, organization, and quality of care: cross-national Findings Nurs. Outlook, 50.187-194
Aiken, LH, Clarke SP, Cheung RB, Sloane, DM, Silber JH (2003) Educational Levels of hospital nurses and surgical patient mortality. JAMA, 290.1617-1623


Posted by Juan José Jurado
English version by Jesús Moreno

Welcome to the English version of Sano y Salvo

Sano y Salvo is currently the only website focused on patient safety in primary care. We receive visits from all over the world, which has made us consider the publication of our contents in English.

So we have created the blog safeanhealthypatient.org, in which we will publish the translation of sanoysalvo.es posts.

Publication at this site of the spanish originals will not be exhaustive or synchronous. We will publish the translation of new posts and, as we can, some of the older posts.

Sano y Salvo is currently a collection of the most relevant items published about patient safety in primary care, both at the national (Spain) and international level. Our web searcher engine and the links on the right column allow anyone to find relevant contents and interesting experiences to improve patient safety in primary care.

Now we also consider making these material worldwide available, in English.


Posted by Jesus Palacio, editor of sanoysalvo.es and Erika Céspedes, manager of the English version published in safeandhealthypatient.org