How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol

EDITOR - We were pleased to see that the BMJ has highlighted the
issue of medical error, the subject of our own programme of research. We
fully endorse the strategy of representing
medical error as a system failure, and the importance of seeking the full
range of root causes underlying particular incidents (1)(2). This strategy
supports prevention rather than the apportioning of blame to individuals.

Our current research in the labour ward has been stimulated by
observational studies, which reported higher rates of error and injury
than might be anticipated (3). Our research involves analysing the system
of care in labour wards in each of 7 maternity units in the North West of
England. Additionally, we will be studying 5 adverse incidents in each
unit. Staff will be interviewed to ascertain the sequence of events. The
cognitive interview technique will be used, which has the ability to
elicit nearly 50% more information than traditional interviewing
techniques (4). The findings will then be analysed using the prevention
and recovery system for monitoring and analysis to discover the root
causes (5). The results will be compared to the analysed system of care
for the individual unit, to provide evidence-based risk management data.

In view of the serious hazards in this speciality, we feel that we have an
obligation to report our initial investigations. These suggest hypotheses
about the sources of risk in current practice in the labour ward.

• lack of formal training and updating on cardiotocograph (CTG)
interpretation for midwifery and medical staff

• inappropriate deployment of midwifery staff due to the 'team
midwifery' system, assigning the least experienced midwives to the highest
risk patients

• dilution of labour wards skills through use of rotational 'team'
midwives, who lack consolidation and confidence

• midwives rotating to labour ward on team basis less familiar with
protocols, including emergency strategies

• reliance being placed on bank midwives for adequate staffing levels

• increased elective procedures, especially caesarean section, which can
produce extra workload where there are tight staffing levels

• inadequate/no supervision of junior medical staff during emergency
procedures

• centrally cited resuscitation apparatus requires transfer of
asphyxiated infants before resuscitation can commence

• increased time constraints through duplicating written records onto
computerised systems, and correcting malfunctioning equipment

Brenda Ashcroft

Lecturer (applied law and ethics in midwifery)
University of Salford,
Allerton Building,
Frederick Road Campus,
Salford

Professor Max Elstein

Executive Director of the Institute of Medicine, Law and Bioethics
at the Universities of Liverpool and Manchester

Williamson Building,
University of Manchester,
Oxford Road,
Manchester. M13 9PL

Professor Nicholas Boreham

Director of Human Factors Research Group

Faculty of Education,
Humanities Building,
University of Manchester,
Oxford Road,
Manchester. M13 9PT

REFERENCES

(1) Vincent C, Taylor-Adams S, Chapman JE, Hewett D, Prior S, Strange
P, Tizzard A. BMJ 2000; 320: 777-81.

(2) Boreham NC, Shea CE, Mackway-Jones K, Clinical Risk and
Collective Competence in the Hospital Emergency Department in the UK.
Social Science & Medicine 2000; 51: 83-91.

(3) Andrews LB, Stocking C, Krizek T, Gottlieb L, Vargish T, Lancet
1997; 349: 309-13

(4) Fisher R P, Geiselman R E, Amador M, Field Test of the
Cognitive Interview: Enhancing the Recollection of Actual Victims and
Witnesses of Crime. Journal of Applied Psychology 1989; 74: 5: 722-27.

(5) Shea C. The Organisation of Work in a Complex and Dynamic
Environment: the Accident and Emergency Department 1996; Ph.D. Thesis,
Human Factors Research Group. Faculty of Education. University of
Manchester.

Linda Pickard
IMLAB Administrator
Room 2.07 Williamson Building
University of Manchester, M13 9PT