Medical errors

doi:10.1136/bmj.322.7299.1421

BMJ 2001;322:1421 ( 9 June )

Letters

Medical errors

Analysis of adverse events must result in improvements in care

Organisational ethos is important

System for reporting errors is not highest priority to decrease errors

Media tend to link error with blame

Perhaps blame-free culture is needed in NHS to reduce errors

Terminology of "error" is important

Errors can have their uses

Courses on crisis avoidance and resource management are available

Different formulations of drugs often look confusingly similar

Appropriate training should avoid accidental intrathecal injection of vincristine

Dosage nomenclature of bleomycin needs to be standardised to avoid errors

Chemotherapy regimens have been formalised into protocols in British Columbia

Medical schools can teach safe drug prescribing and administration

Medical profession must take drug errors seriously

Consent is outdated concept

Analysis of adverse events must result in improvements in care

See also p 1413

The first 150 words of the full text of this article appear below.

EDITOR $---$ In his editorial on medical errors Alberti mentions studies of adverse events from Australia and the United States.¹He then welcomes a paper by Vincent et al²: "Finally, we nowhave some British data from London based on retrospective recordreviews" (of 1014 patients in two acute hospitals inLondon).

In 1980 colleagues and I published a detailed audit of adverse events occurring in 2607 inpatients treated by one surgicalfirm at the Radcliffe Infirmary in 1978.³ Major, moderate,and minor adverse events in adults and children were recordedprospectively, and we made suggestions (which we hoped would benoted by clinicians and administrators) that might encourage wideradoption of this type of investigation so that clinical care mightbeimproved.

In 1990 I wrote an editorial in the BMJ on the findings of the 1989 national confidential enquiry into perioperative deaths(within 30 days of surgery) among children aged under 11.⁴The . . . [Full text of this article]

CiteULike

Complore

Connotea

Del.icio.us Add to Digg

Digg

StumbleUpon Add to Technorati

Technorati What's this?

Relevant Articles

Implementing clinical governance: turning vision into reality: Aidan Halligan and Liam Donaldson
BMJ 2001 322: 1413-1417. [Extract] [Full Text] [PDF]

NHS introduces new patient safety agency: Susan Mayor
BMJ 2001 322: 1013. [Extract] [Full Text] [PDF]

Medical errors: a common problem: K G M M Alberti
BMJ 2001 322: 501-502. [Extract] [Full Text] [PDF]

Not again!: Philip J Bickford Smith, J R C Seale, Saad M B Rassam, Tim Wilson, Anmol Malhotra, Mathew Matson, Otto Chan, and Roger M Goss
BMJ 2001 322: 548. [Extract] [Full Text] [PDF]

Data protection and patients' consent: James I Morrow, Simon J Ellis, Susan Dovey, and Murray Tilyard
BMJ 2001 322: 549. [Extract] [Full Text]

Press: Blunders will never cease • How the media report medical errors • A risky business: Trevor Jackson and Alison Harper
BMJ 2001 322: 562. [Full Text]

How the Atlantic barons learnt teamwork: David Johnson
BMJ 2001 322: 563. [Full Text]

Medication errors that have led to manslaughter charges: R E Ferner
BMJ 2000 321: 1212-1216. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

Jacobson, L., Elwyn, G., Robling, M., Jones, R. T. (2003). Error and safety in primary care: no clear boundaries. Fam Pract 20: 237-241 [Abstract] [Full text]

Rapid Responses:

Read all Rapid Responses

Advice from Sir William...: Paul Gorman
bmj.com, 8 Jun 2001 [Full text]
Medication Errors in Cancer Chemotherapy Referred from External Prescribers: Peter Gilbar
bmj.com, 12 Jun 2001 [Full text]
Consent is outdated concept: Charles A Akle
bmj.com, 17 Jun 2001 [Full text]
Time for practical, multi-disciplinary training to reduce adverse events: James William Parks
bmj.com, 20 Jun 2001 [Full text]