Intended for healthcare professionals

Observations Patient Safety

“Re-cognising” risks: from space shuttles to chest drains

BMJ 2011; 343 doi: (Published 13 July 2011) Cite this as: BMJ 2011;343:d4393
  1. Tara Lamont, scientific adviser to the National Institute for Health Research’s service delivery and organisation research programme and former head of response, National Patient Safety Agency
  1. t.lamont{at}

The NPSA will shortly be abolished in its present form—what have we learnt?

It starts with a meeting at the National Patient Safety Agency (NPSA) to discuss a reported death of a patient from enoxaparin overdose. The national database shows more than 2000 similar incidents reported by staff of dosing errors involving low molecular weight heparins, with varying degrees of harm to patients. How could these be avoided? To the pharmacist present, the solution is clear: doctors just need to be more careful when calculating treatment doses for each patient, by weight and clinical indication. The trainee doctors exchange wry glances—do they know how hard it is to get accurate information about each patient? And to remember the right dose for each of the 10 different heparins used at this hospital? The nurses present look at each other and shrug. What are the chances of any of the medical wards having the right weighing equipment for every patient, including the bedbound, who may need hoists and under-bed scales? And the design expert notes the lack of prompt on the prescribing chart to …

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