Reducing error, improving safety

Abstract

Defensive culture of British medicine needs to change Editor-It was brave to devote a whole issue to medical error 1-how to recognise, how to investigate, how to analyse, and how to change systems to improve patient safety. 1 However, we regret that the edition was dominated by American studies, ignoring the British contribution of confidential inquiries and analyses of closed claims, which have significantly improved safety in some well defined areas of medical practice. In the United States the insurance industry provided the impetus for the study of adverse events, 2 and in Australia the government funded a similar study 3 because it was considering "no fault" compensation. 3 In the United Kingdom, for 25 years the Department of Health has financed all successful claims against NHS hospitals and their staff. As a result the need to take a British study beyond the pilot phase may not be supported. 4 Be that as it may, an important issue was not addressed in the BMJ. Behind each adverse event there is a patient, a doctor, and a doctor-patient relationship. A patient must be told when things have gone wrong. Every effort must be made to minimise the after effects, including financial compensation where necessary. Most patients wish to know in detail what happened and what is being done to reduce the possibility of a recurrence. And members of healthcare teams need mechanisms to come to terms with their fallibility. It is to be hoped that clinical governance will make a difference. Meanwhile a change in the ethos of medical practice is required, and it is to this end that Action for Victims of Medical Accidents has set up a group for doctors. Action for Victims of Medical Accidents is often regarded as dealing solely with compensation and litigation, but its raison d'être has always been to improve patient care. In February this year the doctors' group met informally to discuss how best to translate into practice the General Medical Council's requirements of "good medical practice when things go wrong." 5 We are determined to take our discussion forward and would welcome input from others who see the need to change the defensive and exclusive culture of British medicine. Doctors who would like to be involved should contact Dr Anne Savage, who is acting as secretary to the group.

Patient safety in the operating room: an intervention study on latent risk factors

“…Various studies, however, showed that as an institution improves in the care it delivers and its safety culture more problems may be reported since open reporting is a tenet of safe practice [40]. Increased incident reporting rates may not be indicative of an unsafe organization, but may reflect a shift in organizational culture [41]. In this context it is important to note that the total number of reported incidents more than doubled while the contribution of technical factors to incident causation remained constant.…”

Knowledge Management to Support Performance-based Medicine

“…Moreover, increasing HCOs' performances obviously also requires dealing with the reduction of medical errors. The British Medical Journal very recently devoted a whole issue to this fundamental challenge: how to recognize, investigate, analyze, and change systems to improve patient safety [28]. The error problem can be viewed in two ways: the human approach and the system approach [29].…”

Knowledge and Process Management in Health Care Organizations

“…Health caremustbedelivered by systems thatare carefullyand consciously designed to be certifiablys afe [ 8,9], effective, efficient, andequitable [2]. Such systemsmust be designedt os erve the needso fp atients [10],and thismeans: to ensure thatpatients aref ullyi nformed,r etainc ontrol andp articipate in caredeliverywheneverpossible, andthattheyreceive carethatisrespectful of their valuesa nd preferences [2].…”