The increasing awareness of the frequency and significance of medical
errors and the associated costs to the individual and community creates an
imperative to implement systems that improve the safety of healthcare
delivery. (1)
Errors occur… and errors can be prevented. Other high risk industries have
shown us that the collection of data on errors and incidents, and the
subsequent evaluation can contribute significantly to safety.
The national reporting and learning system (NRLS) as reported by
Katikireddi (2) is a step toward improving patient safety in the NHS.
However, a system for reporting, collecting and analyzing data will only
be successful if the workplace environment supports the reporting of
errors.
Lack of reporting of errors is the most important barrier to
improving patient safety. The vast majority of errors are not reported.
They are not reported because of the fear of reprisal.(3)
Traditional responses to errors in healthcare have been to blame the
individual. Fundamental changes in thinking are essential if progress
is to be made in reporting of errors. Causes of error must be seen as
faults of the system and not faults in individuals. (4) A focus on
individuals diverts attention away from the systemic issues, and therefore
away from the opportunity of systemic improvements.
The high risk industries in which reporting systems have succeeded,
did so through the consistent achievement of a ‘safety culture’. The
approach to errors was non-punitive and proactive, with a focus on sharing
and learning, awareness of the limitations of human performance and the
importance of effective teamwork.(4) Essential to the achievement is
commitment from top management, with continually improved patient safety a
declared and serious priority objective.
The importance of a strong culture of safety is viewed by many as
being the most critical underlying feature of their accomplishments in
improving safety. The NRLS can positively contribute to healthcare safety,
but only to the extent that management prioritize patient safety and
institute a rigorous cultural change in regard to reporting of errors.
Cultural change is essential if improvement in patient safety is to be
achieved.
1.Kohn CT, Corrigan JM, Donaldson MS. To err is human: building a
safer health system. Washington: National Academy Press, 1999: 1-6.
2.Katikireddi V. National reporting system for medical errors is launched.
BMJ 2004; 328 (7438): 481-a.
3. Kohn CT, Corrigan JM, Donaldson MS.Chapter 8:Creating safety systems in
healthcare organizations. To err is human: building a safer health system.
Washington: National Academy Press, 1999: 134-174
4.McNeil JJ, Ogden K, Briganti JE, Loff B, Majoor JW. Chapter 2:Literature
review. Improving patient safety in Victorian hospitals.
Victoria:Department of Human Services, 2000:5-21
Rapid Response:
Improved Patient Safety through Cultural Change
The increasing awareness of the frequency and significance of medical
errors and the associated costs to the individual and community creates an
imperative to implement systems that improve the safety of healthcare
delivery. (1)
Errors occur… and errors can be prevented. Other high risk industries have
shown us that the collection of data on errors and incidents, and the
subsequent evaluation can contribute significantly to safety.
The national reporting and learning system (NRLS) as reported by
Katikireddi (2) is a step toward improving patient safety in the NHS.
However, a system for reporting, collecting and analyzing data will only
be successful if the workplace environment supports the reporting of
errors.
Lack of reporting of errors is the most important barrier to
improving patient safety. The vast majority of errors are not reported.
They are not reported because of the fear of reprisal.(3)
Traditional responses to errors in healthcare have been to blame the
individual. Fundamental changes in thinking are essential if progress
is to be made in reporting of errors. Causes of error must be seen as
faults of the system and not faults in individuals. (4) A focus on
individuals diverts attention away from the systemic issues, and therefore
away from the opportunity of systemic improvements.
The high risk industries in which reporting systems have succeeded,
did so through the consistent achievement of a ‘safety culture’. The
approach to errors was non-punitive and proactive, with a focus on sharing
and learning, awareness of the limitations of human performance and the
importance of effective teamwork.(4) Essential to the achievement is
commitment from top management, with continually improved patient safety a
declared and serious priority objective.
The importance of a strong culture of safety is viewed by many as
being the most critical underlying feature of their accomplishments in
improving safety. The NRLS can positively contribute to healthcare safety,
but only to the extent that management prioritize patient safety and
institute a rigorous cultural change in regard to reporting of errors.
Cultural change is essential if improvement in patient safety is to be
achieved.
1.Kohn CT, Corrigan JM, Donaldson MS. To err is human: building a
safer health system. Washington: National Academy Press, 1999: 1-6.
2.Katikireddi V. National reporting system for medical errors is launched.
BMJ 2004; 328 (7438): 481-a.
3. Kohn CT, Corrigan JM, Donaldson MS.Chapter 8:Creating safety systems in
healthcare organizations. To err is human: building a safer health system.
Washington: National Academy Press, 1999: 134-174
4.McNeil JJ, Ogden K, Briganti JE, Loff B, Majoor JW. Chapter 2:Literature
review. Improving patient safety in Victorian hospitals.
Victoria:Department of Human Services, 2000:5-21
Competing interests:
None declared
Competing interests: No competing interests