Download PDF: Clinical Communiqué December 2018 Edition
In this edition
Editorial
Welcome to the final edition of the Clinical Communiqué for 2018. We finish this year with a double edition, drawing attention to the important lessons covered through the year, and featuring three cases on the theme of doctor-patient communication. We wrap-up our extended edition with a special commentary by a renowned clinician and writer.
As in previous years, our 2018 editions have led our authors and readers through a diverse range of healthcare and patient safety topics. Our intention is to challenge each of us to stop and think about what we can do to ensure that such cases do not recur, and so need never be written about again. Over the past 12 months we looked at the rare but devastatingly fatal complications of gas embolism (Vol. 5, Iss. 1), the difficult clinical scenarios where missed diagnoses occurred in patients presenting to emergency departments (Vol 5, Iss. 2), and the confronting issue of healthcare practitioner suicide (Vol 5, Iss. 3).
The common threads weaving through each of these editions are the importance of building awareness, encouraging reflection, maintaining clinician well-being, and strengthening the systems within which we work. These factors all interact and contribute towards patient safety as demonstrated in the ‘Polygon of Patient Safety’ diagram (see page 2).
The diagram represents the four key goals that clinicians must develop to create real and sustained improvements to patient safety. Building awareness incorporates knowledge of cognitive bias, ‘red flags’ and commonly missed diagnoses, and lessons to be learned from cases. Strengthening systems includes learning from what goes wrong (‘Safety 1’) as well as from what makes high-performing systems work well (‘Safety 2’), and then feeding that input back into systems for continuous improvement.
Encouraging reflection optimises the ability of individuals and systems to improve practice following adverse events, and truly identify the underlying causes, whether through knowledge distribution, or an improved ability to prevent, trap, and mitigate errors.
Finally, clinicians who are unable to look after themselves are more prone to errors, and are sometimes tragically a risk to their own lives. Maintaining well-being through fatigue management, breaking the stigma of mental health and providing support for those in distress, building resilience in individuals, and promoting wellness, is the pathway towards a well-slept, well-trained, and well-supported workforce. This will lead to a healthier environment for both staff and patients.
Whether we are at the beginning of our careers, or carry a wealth of lived experience and skill, we should aim to apply these concepts to our clinical practice. The imperative is promoting the well-being and safety of our patients and, notably, ourselves.