The Pharmaceutical Journal
Vol 270 No 7236 p216
15 February 2003

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Quality and Safety in Health Care abstract (more)

Aviation safety rules can be adapted to prevent outpatient medical errors

Aviation safety principles can be adapted to outpatient care to prevent errors through risk management, a study shows.

Dr Rachel Wilf-Miron, department of risk management, Maccabi Healthcare Services, Tel-Aviv, Israel, and colleagues say that errors are normally seen as an expression of failure and that this creates an environment which precludes the fair and open discussion of mistakes. The principal aim in aviation safety is to prevent accidents through risk management.

The researchers describe the development of a medical risk programme based on aviation safety principles and its implementation in a large outpatient health care organisation over five years (see panel for the principles applied). As part of the programme, medical staff could report errors directly by telephone. Adverse events that had learning potential were analysed.

The researchers report that between November 1996 and August 2001 more than 2,000 incidents took place and, of these, 1,300 entailed accidents or near misses with learning potential.

They used root cause analysis to investigate the adverse incidents and found that of around 1,100 events, 21 per cent were errors in treatment, such as delayed treatment, poor choice of medicine or performing an inappropriate procedure. A third of errors were related to the process of care, including failure to order relevant laboratory tests, failure to refer to a specialist or inadequate review of the patient's history.

The researchers conclude that elements of their approach to risk management could work in other hospital settings. (Quality and Safety in Health Care 2003;12:35).