DIAGNOSING DOCTORS

The paper by Dr Martin Allnutt, a military aviation psychologist, is now 15 years old.¹ That it was published in a mainstream anaesthesia journal that long ago reflects credit on the then Editor of the journal and his staff. For, so far as medicine was (and, regrettably, still is to a degree) concerned, this paper remains ahead of its time. Yet Dr Allnutt would be the first to point out that most of what he says could be regarded by psychologists as mainstream knowledge.²

There are so many concepts and messages in this paper that strike at the heart of error production and which are fundamental to patient safety improvements, that it must be regarded as required reading—by which I mean “understanding and acknowledging”—for all medical practitioners.

Perhaps the most powerful statement in this power packed paper is that it is “an absolutely basic tenet … that all human beings, without any exception whatsoever, make errors and that such errors are a completely normal and necessary part of human cognitive function. For a pilot or doctor to accept that he or she is as likely as anyone else to make a catastrophic error today is the first step towards prevention; whereas to claim exemption on the grounds of being a test pilot, senior professor, commanding officer or consultant, or of having …