Patient safety without the blame gameBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4615 (Published 24 July 2013) Cite this as: BMJ 2013;347:f4615
- Vibeke Lyngklip Svansoe, journalist, drug and healthcare industry
- 1Berlingske, Copenhagen, Denmark
A postoperative patient is transferred from the recovery room to a ward in a Danish hospital. A nurse from the recovery room takes the patient, who is using an oxygen mask, into a side room and gives the doctor a report. It takes another half an hour before a nurse from the ward enters the room to officially receive the patient. She finds the patient in respiratory arrest. The oxygen mask was not replaced by a nasal cannula when the patient came to the ward and the patient can’t breathe properly. Cardiopulmonary resuscitation is started but is unsuccessful.
This is just one of the serious incidents relating to the use of medical devices that was presented in a recent report from the Danish Patient Safety Database.1 Under Denmark’s patient safety act, which came into effect in 2004, health professionals have a duty to report patient safety incidents to the database but can do so without fear that sanctions will be taken against them.
Focus on safety
The problem of patient safety became a priority in most Western countries during the 1990s, and various initiatives were put in place to minimise the risks of hospital treatment. A pilot study by the Danish Institute of Health together with the Ministry of Health and regional authorities in 2001 concluded that 9% of all patients admitted to Danish hospitals were harmed by unintended incidents.2 While other countries passed new legislation aimed at sanctioning the …