Dear Charles,
Thank you for your message where you wrote "On Monday this week a doctor shared a tragic safety episode of a time early in their career in 1986 when a missed diagnosis of epiglottitis (a very rare condition) had a tragic outcome..."
Just to confirm, I was the senior house officer who saw that child in 1986.
Back then it was never explained to me that "clinical staff are often 'set up to fail' by the systems they work in, as the story of the missed diagnosis showed us". Indeed, there was probably little awareness of system factors per se. There were multiple system factors in my case.
It is encouraging that "our understanding and approach to safety in healthcare has completely transformed" compared to the 1980s, and yet I imagine this is true for only a few countries. Worldwide, I suspect that "blame and recrimination are still far too common"?
Thanks again for your input Charles. We are fortunate to have you as one of the world's leading experts on patient safety.
(Incidentally, for the past 40 years until this week, I had not been aware that epiglottitis is notoriously difficult to diagnose, with as many as 80% of cases missed on first assessment. I wish I had understood this at the time.)
Best wishes, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org