Patient safety: a work in progress
We welcome the Sixth Report of the Health Committee on Patient
Safety. The committee appear to have recognised the priority that has been
given to patient safety in recent years, but also highlights that services
are safe enough yet1.
One area that we feel the report has misjudged is the suggestion that
more emphasis should be placed on serious events with less attention to
common events. The tragic case of Wayne Jowett, who received a fatal
injection of an anti cancer drug at the wrong site is given as an example.
However, research has shown that less than 30% of adverse events result in
death or severe injury2. Common and minor events should be taken seriously
- the analogy of an iceberg may be appropriate with the burden of the
morbidity lying below the surface.
Furthermore, the root causes of all adverse events including ‘near-
miss’ situations, have the same underlying patterns of failure. High
reliability industries, such as the aviation industry are well known for
treating near-misses and minor adverse events with as much rigor as those
that result in death or permanent disability. By addressing near-misses
and minor adverse events, the underlying causes can be corrected before
they lead to a disastrous incident3,4.
The report states that systematically reviewing samples of patients’
case notes at periodic intervals should be undertaken to record data on
adverse events. However, there is evidence that more intensive
investigation, including discussion with healthcare professionals, gives a
higher yield of information on these events5.
Addressing and improving patient safety is an ongoing process that
needs to be embedded in the culture and practices of the NHS6. Progress
has been made, but there is much more to do.
Benjamin Lamb MRCS
Kamal Nagpal MRCS
The authors have no competing interests to declare.
1. Patient Safety, Sixth Report of Session 2008–09, Volume I.
Department of Health. 18 June 2009
2. Brennan TA et al. Incidence of adverse events and negligence in
hospitalized patients. Results of the Harvard Medical Practice Study I. N
Engl J Med. 1991 Feb 7;324(6):370-6.
3. Reason, J. T. (2000). "Human error: models and management". British
Medical Journal 320 (7237): 768–770.
4. Gambino R, Mallon O. Near misses an untapped database to find root
causes. Lab Report 1991; 13: 41-44
5. Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al.
Incidence of adverse drug events and potential adverse drug events. JAMA
6. Long et al. Practising safely in the foundation years. BMJ (2009) vol.
338 pp. b1046
Competing interests: No competing interests