“Weak” safety culture behind errors, says chief medical officerBMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7384.300/b (Published 08 February 2003) Cite this as: BMJ 2003;326:300
Incidences of serious medical errors in clinical practice are rarely solely the fault of individual healthcare workers but are the fault of the entire system, Professor Liam Donaldson, England's chief medical officer, told NHS managers at a conference on patient safety in London last week.
“Twenty five per cent of medical errors worldwide are caused by medication errors alone,” he noted in his keynote address.
For errors occurring in the United Kingdom, he blamed poor design of the NHS's safety systems, inadequate reporting processes, and a lack of specific protocols, which he said had resulted in a “weak” safety culture.
Currently in the United Kingdom, 10% of inpatient episodes lead to unintended harm. Around half of these are deemed by researchers to be preventable. Professor Donaldson discussed the need to lessen what he termed “blame culture” in the system. “We need to create an environment in which employees can admit when there are problems if we are to tackle whole system failings that lead to errors.”
“The new National Patient Safety Agency is a unique endeavour to build a centralised reporting system to improve safety conventions throughout the NHS,” Susan Williams, the agency's joint chief executive, told participants at the conference, which was organised by the Health Service Journal.
The agency, set up in July 2001, aims to collate reports on adverse incidents and “near misses” in the United Kingdom, analyse trends in errors, and implement local and national solutions. It has also commissioned research into specific issues, Ms Williams said.
“For example, we have noticed a trend in errors occurring in decisions made by clinicians at the end of busy clinics; when clinicians ‘squeeze someone in’ in an attempt to be helpful to the patient.” The agency is also investigating system changes to prevent dosage errors of the drug methotrexate, overdoses of which in the past six years have caused 17 UK deaths.
Some managers felt that a centralised system for patients themselves to report errors would also be welcome.
Professor Angela Coulter, chief executive of the Picker Institute Europe, said: “Negative media reporting means that patients now need to be reassured that systems are in place within the hospitals they go to, to reduce clinical errors.”
“Our research shows that patients do now want information on quality of care, health outcomes, and doctoral skills and qualifications,” said Professor Coulter, adding that patients' views still seemed to be divided on the need for star ratings to compare performances of service providers.