Improving patient safety by learning from mistakes: The Cappuccini Test

At 100 Aldersgate in the City, last week, I experienced one of the most satisfying moments of my career.  I was with the family of Frances Cappuccini as a guest of the Royal College of Anaesthetists to hear Dr David Bogod’s lecture about a test he has developed. The test seeks to prevent recurrence of the events that led up to Frances’s death and is named after her.

The test is beautiful for its simplicity and the hope is that it will gain significant traction. It may even be used for other specialisations beyond anaesthesia.

To be with Frances’ family and witness a step towards the ultimate goal (of all of my clients) that “this will never happen to somebody else” was an honour.  Patient safety is not necessarily about ground breaking changes it can be about diligence and adherence to protocols and this audit tool will help to ensure that safer environments are created. 

With the family’s consent here are two quotes that I would like to share with you, they say it all:

Julia Cording (Frances' mother):

“This really does create a legacy.”

Tom Cappuccini (Frances’ husband): 

“One of the things I like about this test is it protects junior doctors (and even consultants too) as well as patients.”