Intended for healthcare professionals

Rapid response to:

Education And Debate Quality improvement report

Learning from adverse incidents involving medical devices

BMJ 2002; 325 doi: (Published 03 August 2002) Cite this as: BMJ 2002;325:272

Rapid Response:

Giving quality the common touch

Dear Editor,

It was pleasing to read of such an enlightened but simple approach to
preventable adverse incidents in BMJ 2002/325:272-275 (August 3). For too
long the term ‘quality’ has been bandied about by the academics and
administrators who seem to want to keep the idea for themselves, and their
staff in the dark. Amoore and Ingram (1) are doing their part to make the
idea of quality improvement a meaningful one.

A ‘quality’ approach needs to be a systems approach if it is to
succeed (2). Unfortunately the methods used to convey this message to
staff can be too academic and alienate them from the quality process.
Those involved in the development of quality programs too often use
expressions that are meaningless and irrelevant to those they are hoping
to inspire. Staff need tangible outcomes that show the system working and
encourage them to participate in the process. The development of feedback
notes is an example of such a positive tool.

The feedback note promotes a ‘no blame’ system with an educative
element (1). Detailing the positive actions taken by staff, as well as the
causes and events that led to error is an excellent method of engendering
an open reporting culture. It is encouraging to note that the staff are
now more forthcoming with information about adverse events in relation to

The final step in the feedback note process, that of sharing the
information anonymously throughout the organisation, ensures that as wide
a audience as possible can use this experience to learn and improve their

The increasing use of medical technology creates an environment with
increasing potential for adverse events, despite the best efforts to the
contrary (3). Errors when using medical devices arise as a result of a
variety of factors from knowledge deficit, poor storage, inappropriate use
etc. (1). In the health care industry adverse events can never be totally
prevented, but we can work towards risk management and minimising severity
by analysing these event sin a non-punitive way.

The feedback note approach taken at the Royal Infirmary of Edinburgh
is innovative in that the process is a meaningful one for staff. As a
component of a quality program, it provides an excellent tool to
demonstrate the actual benefits that can be achieved by a commitment to
quality, and one that will be instigated within my own organisation.

(1) Amoore JN, Ingram P. Learning from adverse incidents involving
medical devices. BMJ 2002; 325:272-275

(2) McNeil JJ, Ogden K, Briganti E, Ibrahim JE, Loff B, Majoor JW.
Chapter 2: Leterature review. Improving patient safety in Victorian
hospitals. Victoria: Department of Human Services, 2000: 14

(3) Kohn CT, Corrigan JM, Donaldson MS. Chapter 8: Creating safety
systems I health care organizations. To err is human: building a safer
health system. Washington: National Academy Press, 1999: 139

Competing interests: No competing interests

09 August 2002
Margaret Kuhne
Community Health Coordinator
South Gippsland Hospital Station Road Foster 3960