Letters

Medical errors

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7299.1421 (Published 09 June 2001) Cite this as: BMJ 2001;322:1421

Analysis of adverse events must result in improvements in care

  1. M H Gough, honorary consultant surgeon
  1. Church End, Bletchington OX5 3DL
  2. Royal Gwent Hospital, Newport, Gwent NP9 2UB
  3. Mill Stream Surgery, Benson, Wallingford OX10 6LA
  4. Brighton Health Care NHS Trust, Royal Sussex County Hospital, Brighton BN2 5BE
  5. Northampton General Hospital, Northampton NN1 5BD
  6. University of Sunderland, Sunderland SR2 7BW
  7. Lancet, London WC1B 3SL
  8. Scottish Clinical Simulation Centre, Stirling Royal Infirmary, Stirling FK8 2AU simulator@scsc.co.uk
  9. Royal Hallamshire Hospital, Sheffield S10 2JF
  10. Royal Marsden Hospital, London SW3 6JJ
  11. Drug Information Service, Peter MacCallum Cancer Institute, St Andrew's Place, East Melbourne, 3002, Australia
  12. Research and Cancer Services, Austin and Repatriation Medical Centre, Heidelberg, 3084, Australia
  13. Provincial Systemic Therapy Programme, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, British Columbia, Canada V5Z 4E6
  14. University Department of Therapeutics, Queen Elizabeth Hospital, Birmingham B15 2TT
  15. West Midlands Centre for Adverse Drug Reaction Reporting, City Hospital, Birmingham B18 7QH
  16. National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG
  17. Solent Department of Urology, St Mary's Hospital, Portsmouth NHS Trust, Portsmouth PO3 6AD

    See also p 1413

    EDITOR—In his editorial on medical errors Alberti mentions studies of adverse events from Australia and the United States.1 He then welcomes a paper by Vincent et al2: “Finally, we now have some British data from London based on retrospective record reviews” (of 1014 patients in two acute hospitals in London).

    In 1980 colleagues and I published a detailed audit of adverse events occurring in 2607 inpatients treated by one surgical firm at the Radcliffe Infirmary in 1978.3 Major, moderate, and minor adverse events in adults and children were recorded prospectively, and we made suggestions (which we hoped would be noted by clinicians and administrators) that might encourage wider adoption of this type of investigation so that clinical care might be improved.

    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 11.4 The editorial's concluding sentence was: “If clinical information services are improved … then an even more formidable task may lie ahead: the investigation of perioperative morbidity.”

    In 2000, England's chief medical officer suggested that a national system for recording adverse events should be set up.5 This suggestion has Alberti's support, although he describes it as an enormous undertaking. I hope that we will not have to wait yet another decade before the analysis of data concerning adverse events leads to action being taken to improve care. Prompt action by the Department of Health to provide the resources necessary for this initiative would go some way to compensate for the previous delays.

    References

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    Organisational ethos is important

    1. Paul Buss (pbuss@doctors.org.uk), consultant paediatrician
    1. Church End, Bletchington OX5 3DL
    2. Royal Gwent Hospital, Newport, Gwent NP9 2UB
    3. Mill Stream Surgery, Benson, Wallingford OX10 6LA
    4. Brighton Health Care NHS Trust, Royal Sussex County Hospital, Brighton BN2 5BE
    5. Northampton General Hospital, Northampton NN1 5BD
    6. University of Sunderland, Sunderland SR2 7BW
    7. Lancet, London WC1B 3SL
    8. Scottish Clinical Simulation Centre, Stirling Royal Infirmary, Stirling FK8 2AU simulator@scsc.co.uk
    9. Royal Hallamshire Hospital, Sheffield S10 2JF
    10. Royal Marsden Hospital, London SW3 6JJ
    11. Drug Information Service, Peter MacCallum Cancer Institute, St Andrew's Place, East Melbourne, 3002, Australia
    12. Research and Cancer Services, Austin and Repatriation Medical Centre, Heidelberg, 3084, Australia
    13. Provincial Systemic Therapy Programme, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, British Columbia, Canada V5Z 4E6
    14. University Department of Therapeutics, Queen Elizabeth Hospital, Birmingham B15 2TT
    15. West Midlands Centre for Adverse Drug Reaction Reporting, City Hospital, Birmingham B18 7QH
    16. National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG
    17. Solent Department of Urology, St Mary's Hospital, Portsmouth NHS Trust, Portsmouth PO3 6AD

      EDITOR—Alberti highlights the possible magnitude of the problem facing the NHS with regard to medical error, but he makes little mention of clinical governance.1 In its …

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