In 2008, Julie Carman was involved in a road traffic accident whilst on a cycling holiday. She suffered injuries to her face, jaw and legs but made a good initial recovery and expected to be back at work within three months.Three years later she was still having treatment having experienced two further emergency admissions to hospital due to acute cellulitis and sepsis.In this short film Julie explains how a series of “everyday” communication failures conspired to create delays in her receiving effective treatment. These delays and the resultant risk to her life led to a slower physical and psychological recovery and in Julie’s view were very probably avoidable. Julie, a former NHS employee, speaks of her feelings of shame and concern at the level of avoidable harm in the healthcare system and appeals to healthcare professionals to take a long hard look at their practice as a result of listening to her story.
This powerful story clearly illustrates how inadvertent system errors can lead to serious harm to patients as well as significant added costs to the system. The story also points towards a more systemic and standardised approach to care and suggests that a better understanding of human factors could make a difference.
“Julie’s Story brought the real human impact of patient safety to the clinical staff in a way that no other medium could. Staff felt that the message was balanced and focused on learning rather than blame, whilst also showing quite clearly the gaps that occur in the care pathway when communication and teamwork fail.”
Dr Trisha Bain, Deputy Director of Quality Standards, The Rotherham Hospital NHS Foundation Trust
This film can be viewed alongside another short film entitled ‘Surviving Sepsis‘. Working with Dr Matt Inada-Kim and colleagues at Royal Hampshire County Hospital, part of Winchester and Eastleigh Healthcare NHS Trust, we’ve made a short film to document the innovative human factors-based approach that they have developed to tackle the identification and management of severe sepsis. Using a combination of audit, simulation training and practical tools to aid decision-making, the team have developed a comprehensive training and development package which they are currently spreading throughout South Central SHA.
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