WHO Patient Safety Champion Rebecca O'Malley tells compares standards in the food industry and healthcare and asks why it is acceptable to allow such variation in quality in healthcare services. Recorded at the 1000 Lives Plus National Learning Event, Liberty Stadium, Swansea.
International patient safety advocate Rebecca O’Malley gave the keynote address at the 1000 Lives Plus National Learning Event. She explains how her life changed following her misdiagnosis with breast cancer, and why she has campaigned since for safer patient care.
When mother of three Rebecca O’Malley received the all-clear following an examination on a lump found in her breast, she was delighted to be able to carry on her life as normal.
Fourteen months later, she was facing a mastectomy and life saving treatment after discovering she had breast cancer and had been wrongly given the all-clear.
Her misdiagnosis and subsequent delay in crucial treatment had led to the cancer silently growing in her breast and spreading to her lymph nodes.
At the age of just 40, she was, as she so simply puts it, ‘heading for disaster’.
“It was so hard for myself and my family,” said Rebecca, who told her story to over 300 NHS Wales staff at the 1000 Lives Plus event.
“My husband had already lost his mother to breast cancer when he was just nine years old and now he and our three young children were facing the prospect of history repeating itself.
“We decided we had to be open with our children, but when the eldest asked me to promise that I wouldn’t die, it was the hardest thing to tell her that I couldn’t make that promise.”
After persistent questioning of her hospital in Ireland, Rebecca discovered that her previous results had been incorrectly reported. Yet even after finding this out, the hospital staff were reluctant to carry out a thorough investigation into what had gone wrong.
She said, “It would have been easier to leave it alone, it wouldn’t change anything but I couldn’t do it, inaction was not appropriate. If this could happen to me, it could happen to anyone and I needed to make sure changes were made.”
Rebecca took her case to the highest level of Government, which ensured changes were made to breast cancer services in Ireland. Now, she is continuing her mission to put patients at the centre of care. She is now a World Health Organisation international patient safety advocate.
A right to ask
At the recent learning session Rebecca championed a culture where patients have the right to ask questions in NHS Wales, and she commended NHS Wales staff for the achievements made in the 1000 Lives Campaign and 1000 Lives Plus.
She said, “We all have to recognise that errors are made, that systems do fail and that people will be harmed.
“But you have to make sure you are ready for errors, expect them and act on them to make sure it doesn’t happen again.
“The work you have already done as part of 1000 Lives is making a huge difference and has spared many families anguish because of improvements made.
“Now you have to set your standards even higher. You have to aim for zero hospital falls, zero pressure ulcers, zero thrombosis.
“You have thousands of patient voices in your system and each one of them is a quality control officer seven days a week, 24 hours a day – just listen to them.”
She said, “Patients need to be partners in their own care, they have to have the opportunity to speak and to challenge consultants. It has to be an equal relationship.
“Patients can be a powerful catalyst for change, they need to be involved in the safety agenda and should be at the pinnacle of all thinking.
“It is beholden on everybody who works in the health service, whenever something such as this happens, not just to be able to sit back and think, "Well, at least it is not my hospital."
“Professional egos must be left at home. We must all look at our own hospital and identify what might be happening there. And once it is identified lets act straight away to put it right.”
Rebecca believes that many of the improvements already being delivered in Wales, such as patient safety walkrounds and the surgical safety checklist, are vital to ensuring communication is open and transparent. She said,“I’m very impressed with the work which has been delivered by the 1000 Lives Campaign and now by 1000 Lives Plus.
“You have to show by your actions that patient safety is important to you and the new ways of working you have introduced have made a big difference to patient care.
“If you look at what the 1000 Lives Campaign achieved, just think about how much difference 1000 Lives Plus can make over five years.”
Link to Rebecca's Powerpoint: http://www.1000livesplus.wales.nhs.uk/news/20513