We need to develop wider vision to reduce errors

doi:10.1136/bmj.a1500

Published 3 September 2008, doi:10.1136/bmj.a1500
Cite this as: BMJ 2008;337:a1500

Letters

Medical error

We need to develop wider vision to reduce errors

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

A recent BBC radio programme highlighted the case of an airlinepilot’s wife who died unexpectedly during surgery. Thepilot was surprised by the lack of seriousness in investigatingthe incident. In his review of the programme, Ferner remarkedon the many differences between aviation and medicine, whichneed to be acted on.¹ He applauded the airline industry forits reporting, no-blame culture, and teamwork, which not solong ago were clearly lacking.

Bertil Jacobson, emeritus professor of medical engineering atthe Karolinska Institute in Stockholm, has reported on manyincidents involving medical devices and thinks that incidentsare still needlessly common. Together, we have compiled casehistory reviews of 140 medical incidents in which many deathsand injuries occurred.² These reviews are written in simplenon-technical language and are accompanied by descriptions ofthe medical devices and technology involved in such incidents.Lack of teamwork was a pervasive theme, . . . [Full text of this article]