The National Health Service is to learn from aviation and other industries' experience of analysing adverse incidents.
The Department of Health announced on June 13 that a reporting system for recording all failures, mistakes, errors and near-misses in health care would be established by the end of the year. The decision implements the recommendations of a report produced by an expert group led by the chief medical officer (Professor Liam Donaldson).
The recommendations called for: a mandatory reporting scheme for adverse events based on standardised systems and clear definitions; a single database for analysing and sharing lessons with data to identify common factors and action to reduce risks; a reporting and questioning, rather than blaming, culture; and improved investigations.
The Department said that NHS organisations were already required to have reporting systems, but that there was little consistency around the country. There was no single system for assessing adverse events and feeding lessons to the NHS as a whole.
Research suggested that as many as 850,000 adverse events occurred each year in NHS hospitals. The financial cost of these was difficult to estimate, but probably exceeded £2bn a year. One example of persistent failure to learn lessons was spinal injections. At least 13 patients had died or been paralysed since 1985 because medicines had been wrongly administered by spinal injection.
A specific target set in the report is to reduce by 40 per cent the number of serious errors in the use of prescribed medicines by 2005. Currently, such mistakes account for 20 per cent of all clinical negligence litigation.
The report says that 70 per cent of adverse incidents are preventable. It accepts that although errors can be minimised they will never be completely eliminated, particularly where high volumes of activity occur. It says that it has been estimated that a 600 bed teaching hospital with 99.9 per cent error free drug ordering, dispensing and administration will experience 4,000 drug errors a year. Measures also need to be taken to limit the adverse consequences of those errors that still occur, it says. This involves designing or modifying systems so that they are better able to tolerate inevitable human errors and contain their damaging consequences.
"An organisation with a memory". The Stationery Office, ISBN 011 322441 9, price £14.40. Also available on the internet (www.doh.gov.uk/orgmemreport/index.htm).