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09 Sep 2019


I bought a motorcycle in March. I know; the obvious choice for a guy who works in ED and ICU. Nothing huge mind you. Just a simple 250cc Honda that goes where I need it to go.

I had no idea at the time that I had just purchased an instant dichotomy generator. See, my bike generally elicits one of two responses. Either you think that motorbikes are the greatest thing since sliced bread, or you are convinced I’m going to die in a fiery blaze of pain and suffering. Now for a population where roughly 4 in every 100 passenger vehicles is missing two wheels, I was amazed at just how many people had strong opinions on my impending death, invitation-less as they may have been.

This is not an esoteric topic. We’ve got the data to prove to you whether I have increased my risk of death or not, and yet the feedback was anything but definitive. And in forecasting my death, I found a number of factors missing

In their decision making process. Was I wearing a helmet? Was I wearing protective clothing? Did I ride at night? Did I ride drunk? Where did I ride and under what road conditions? Did I carry passengers? Am I male or female? How old am I?

These are easily more important variables, but the jury had made its choice without this data. Motorcycles equals death, or joy. Risk was definitely not in the eye of the beholder, but everyone else. This process became a daily reminder, and my thoughts moved to risk in health care. It’s not a new topic, not by a long shot. But our risk management systems are as broken as the opinions on my motorcycle. I want you to picture where you work. Conjure up your practice or hospital, and mentally advance through your day. How many practices or situations can you imagine that you would consider a risk to patient safety? There are more than you’d care to admit, but we have no tools with which to address them in a meaningful manner.

And it’s not your fault. You see, you’re either suffering from risk normalisation or risk fatigue. If you’ve ever submitted a risk management report and watched it fall into a large vortex with no meaningful follow-up or outcome, you’re risk fatigued. If you notice the risk, but everyone around you is saying “this is fine” as the house burns down, you’re suffering from risk normalisation. I’d argue that every doctor in Australia falls into one of these two categories, with the exception of interns and the mad. And I need you to get mad. I need you to get mad, because nothing is going to change until you do. You’re the person who sees the patient. You’re the one with that intimate contact and understanding. You’re the patient’s strongest advocate, save for the patient themselves.

So you can’t afford not to be mad. And besides, aren’t you sick of it? I don’t believe that any of you are shocked by the media this month surrounding 24-hour ED wait times in one of Australia’s newest hospitals. But you don’t have to look too far to find tales of woe in your own neighbourhood. And patient safety doesn’t rely on the single primary treating doctor. It relies on everyone with any degree of contact with the patient as they make their way through the opaque waters of our healthcare system.

Are you the ortho reg passing through the over-census ED who can’t make the wheels turn in theatre bookings for your open reduction? Guess what. Your problem too. Are you the RMO covering a private ward somewhere, who is continually stuck working late because of the lack of clinical escalation systems? Your problem too. Are you the clinical executive member who hasn’t invested in a clinical redesign unit/program/manager? Most definitely your problem.

Risk should not be viewed as only negative. Change is constant and change carries risk. Without risk, we’d be stuck in the medical Middle Ages. However, we’re no longer managing risk in a prospective way that can correct hazards. We’re managing it in a reactive way that only cleans up after the disaster. It’s for this reason that I believe that anyone who blames poor hospital performance on winter, an entirely predictable change in the weather that has occurred on an annual basis below the Tropic of Capricorn since time immemorial, should instantly be fired on the spot. Risk is present every day. And every day, corporate directors are deciding on the risk appetite for the management of their company.

So if it’s good enough for Bunnings to help keep my house in order at the right price point, why the hell isn’t it good enough for my patients when it comes to their literal life and death? Risk management in Australian hospitals is broken, and it needs to be rebuilt. We can’t claim to be acting in the best interests of our patients until we start to demand more from those who manage risk in our hospitals and practices. Risk appetites need to be set by executives with appropriate clinical information. Risk management systems need to be timely, relevant and most importantly need to be closed loop. And whistleblowers need to be empowered to speak against those places of work with a toxic risk culture.

Otherwise, who will put me back together when I finally come off of my motorcycle?

Published: 09 Sep 2019