Intended for healthcare professionals

Education And Debate

Framework for analysing risk and safety in clinical medicine

BMJ 1998; 316 doi: (Published 11 April 1998) Cite this as: BMJ 1998;316:1154
  1. Charles Vincent, senior lecturer (,
  2. Sally Taylor-Adams, HHRI lecturer in clinical risk,
  3. Nicola Stanhope, research fellow
  1. Clinical Risk Unit, Department of Psychology, University College London, London WC1E 6BT
  1. Correspondence to: Dr Vincent
  • Accepted 31 October 1997

Adverse events are incidents in which a patient is unintentionally harmed by medical treatment. Awareness while under anaesthetic, deaths during surgery, and missed cases of meningitis are tragic for both patients and staff, and may lead to complaints or litigation. Investigations usually focus on the actions of individual doctors and seldom examine the background to these events.

In a recent case of a patient whose bowel was perforated during surgery, examination of the medical records led to criticism of the surgeon. Only later did it emerge that the operation had been carried out in near darkness because of several equipment and power problems. Adverse events usually originate in a variety of systemic features operating at different levels—the task, the team, the work environment, and the organisation. We present a framework that aims to encompass the many factors influencing clinical practice. It can be used to guide the investigation of incidents, to generate ways of assessing risk, and to focus research on the causes and prevention of adverse outcomes.

The original model for accident assessment was developed for use in complex industrial settings such as offshore drilling platforms

Summary points

Adverse events in which patients are harmed by medical treatment are common

Investigations which consider only actions or omissions of individual clinicians are incomplete and misleading

Psychological research shows that liability to error is strongly affected by adverse conditions of work

These conditions include high workload, inadequate supervision, poor communication, rapid change within an organisation

A framework of risk factors allows a systematic approach to safety and error reduction

Adverse events

In spite of increased attention to quality, errors and adverse outcomes are still frequent in clinical practice.1 The risk of iatrogenic injury to patients in acute hospitals remains high, with studies reporting rates of 4-17%.2-4 A recent American observational study found that …

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