Medical error: the plane truth
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1281 (Published 12 August 2008) Cite this as: BMJ 2008;337:a1281
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Ferner (1) addresses safety in surgical practice, a topic of
considerable current global interest. In industrialized countries, almost
half of all adverse events in hospital patients are related to surgical
care. Of these, at least half are considered to be preventable if
standards of care are adhered to and safety tools such as checklists are
used. Yet published data suggests known principles of surgical safety are
inconsistently applied.
The Safe Surgery Saves Lives initiative was established by the World
Alliance for Patient Safety as part of the World Health Organization’s
efforts to reduce the number of surgical deaths across the world. The aim
of this system-wide approach is to address important safety issues,
including inadequate anaesthetic safety practices, avoidable surgical
infection and poor communication among team members. These have proved to
be universal problems in all countries and settings.
A key component is the WHO Surgical Safety Checklist (2) which
identifies three phases of an operation, each corresponding to a specific
period in the normal flow of work – pre induction, pre incision, and a
‘sign out’ before the patient leaves the operating theatre. Prior to these
specific phases of perioperative care, the whole operating team -
surgeons, anaesthetists, and nurses – discuss key safety checks. Not only
are particular safety issues identified, proactive team communication is
also improved.
Local experience with the Scottish Patient Safety Programme suggests
that checklisting requires very minimal resource commitment, very little
extra time to perform and that the key to successful implementation is to
start small, for example in a single operating theatre, and then roll out
the process from there.
Error in human activity will always be inevitable. However,
preliminary evaluation in 8 pilot sites worldwide has shown that it can be
substantially reduced - the checklist has nearly doubled the likelihood
that patients will receive treatment as per standard of surgical care.
References
1.Ferner RE. Medical error: the plane truth. BMJ 2008; 337: a1281
2.Checklists save lives. WHO Bulletin 2008; 86(7): 497-576
Competing interests:
None declared
Competing interests: No competing interests
Reducing medical errors and incidents: a wider vision
We all agree that medical errors and incidents must be reduced as far
as possible. This issue is rightly at the forefront of much discussion. In
the UK help is provided by the National Patient Safety Agency (NPSA) and
the Medicines and Healthcare products Regulatory Agency (MHRA), the latter
dealing specifically with aspects of drug and medical device safety. It is
important in this discussion to retain a wide vision and not assume that
there will be a single fix. A recent BBC radio programme highlighted a
personal NHS tragedy for an airline pilot who was subsequently surprised
by the lack of seriousness in investigating the incident. Robin Ferner, in
his review of the programme, was positive about the efforts of the pilot,
but drew out the differences between aviation and medicine (1). There are
many differences that we rightly need to address, but we need to applaud
the airline industry for its reporting, no-blame culture and teamwork,
which not so long ago was clearly lacking.
Bertil Jacobson, Emeritus Professor of Medical Engineering at the
Karolinska Institute in Stockholm has reported on many medical device
incidents during his long career in medicine, and is convinced that
incidents are still needlessly common. Together we have compiled case
history reviews of 140 medical incidents, sadly involving many deaths and
injuries (2). These have been written in simple non-technical language to
communicate with all involved in medical care, and have parallel
descriptions of medical devices and technology involved in such incidents.
Lack of teamwork was a pervasive theme, including an unclear awareness of
where actions taken in isolation may lead, and a lack of understanding of
the technology being used.
We need to develop a wider vision with a culture in which teamwork,
reporting, no-blame and a better understanding of medical technology is
the norm.
References
1 Ferner R. Medical error: the plane truth. BMJ 2008:337:a1281.
2 Jacobson B, Murray A. Medical devices: use and safety. Edinburgh:
Churchill Livingstone, Elsevier, 2007.
alan.murray@ncl.ac.uk
Competing interests:
None declared
Competing interests: No competing interests