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First do no harm; then try to prevent it
  1. Geoffrey Hughes
  1. Correspondence to:
 G Hughes The Emergency Department
 Royal Adelaide Hospital, North Terrace, Adelaide 5000, Australia;cchdhb{at}

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First do no harm, “primum non nocere”, is a doctrine as old as medicine itself, frequently but probably inaccurately attributed to Hippocrates, the wise old man of our profession.

Prevention of injury and illness is another significant aspect of medical practice. The profound impacts it has had on society, largely taken for granted in the industrialised world but less so elsewhere, are extraordinary; immunisation, sanitation, screening programmes, road safety initiatives—the list goes on—have changed our lives to degrees unimaginable even 30, let alone 100 years ago. Although it is an important component of our profession it is underplayed in both training and our day-to-day activity. It is encouraging to know that it will be part of our new curriculum, despite the time constraints and rationalisation imposed by the modernising medical careers platform. This is consistent with the philosophy of the World Health Organisation1 which emphasises the role that doctors have to play in preventive medicine.

Two publications, released within a few days of each other in February, challenge our specialty to be more involved in this work.

The Healthcare Commission ( in Better safe than sorry: preventing unintentional injury to children (thankfully not described as the paediatric population) reports that each year approximately two million accident and emergency (A&E) attendances are by children injured from accidents that could have been prevented; 3 in every 100 000 children are killed for the same reasons, and the cost to the NHS is £146 ($ 282.26, €212.74) million a year. Knowledge of and insight into the underlying causes of children’s injuries is apparently unclear and the true number of injuries unknown. There is one frightening and stunning statistic: children of parents who have never worked or who have been unemployed for a long time are 13 (yes—13) times more likely to die from unintentional injury than those of parents in managerial and professional occupations. This fact synchronises with the findings of a recent Unicef publication ( on the well-being of children, a report placing Britain 21st out of 21 rich countries. The government will be pleased to see the use of a league table, a philosophy they have espoused since coming into office, even though bottom place is an embarrassment for them.

The Healthcare Commission report is detailed and lengthy, with sections devoted to the role that A&E departments, as well as other groups, can play in tackling the problem. Our contribution can be split into two categories, one strategic, aimed at refining data collection, and the second operational, aimed at communication and information sharing with both the public and professional organisations.

A few days after the Commission published its report, the Royal College of Psychiatrists ( published a survey revealing that the attitudes and behaviour of A&E staff are the most important and significant factors that affect the experience of care among patients who harm themselves. The survey, from the College’s Quality Improvement Centre, is based on the responses of >500 people. In a nutshell, patients are better able to cope after discharge from A&E if staff are respectful, positive and non-judgemental. The significant minority who are told that they are wasting hospital time and resources, often coupled with an undercurrent of hostility, can and do self-discharge to self-harm again almost immediately.

Although patient satisfaction surveys are criticised as a flawed means with which to get objective data, they still provide important qualitative information. This method is part of everyday life these days, from political opinion polls to straw polls asking for our opinions on virtually anything you care to mention. Patient satisfaction surveys are the equivalent of having a lay consumer representative on a hospital quality committee. On this basis the findings of the survey need to be taken seriously.

The College of Psychiatrists has a programme that our specialty may be unaware of, Better Services for People who Self-Harm. The manager of this programme says that patients who harm themselves want to be treated with the same respect as any other patient group and do not want to be discriminated against. This is so self-evident that it barely needs commenting on, apart from the fact that we should be embarrassed that these negative attitudes still prevail. It is an important message for us to take on board. We need to acknowledge the criticism and respond positively, just as we need to be involved in reducing injuries to children, an initiative that will also have the positive spin-off of lessening our clinical load.

First do no harm; then try to prevent it.


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  • Competing interests: None declared.

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