Learning from adverse incidents
Adverse incidents with medical devices are caused by a variety
of factors and not simply by faulty devices or user error. Each year
about 400 people are killed or seriously injured in adverse incidents
with medical devices. Amoore and Ingram (p 272) describe the
development of a feedback note on adverse incidents; the note describes
the incident and gives generic details of the equipment and lessons to
be learnt by staff. A careful analysis of each adverse incident, the
authors say, can reveal the multifactorial causes of the incident and
the good practices that can help minimise repetitions.
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- Quality improvement report: Learning from adverse incidents involving medical devices
- John Amoore and Paula Ingram
BMJ 2002 325: 272-275.[Abstract] [Full Text] [PDF]
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