We need the facts to win the ‘war on error’ in hospitals

Article in The National from the United Arab Emirates by Justin Thomas on 26 April 2009

Thomas is assistant professor in the Department of Natural Science and Public Health at Zayed University. He presented at a conference for health care professionals on the topic of "patient safety."

He says "patient safety is an important and complex issue that touches on the psychology of human error, risk management, medical negligence, freedom of information and corporate manslaughter litigation" and gives two examples from the UK:

In one case an elderly woman had been admitted for a fairly routine overnight stay. She choked on some toast. The ward staff did not know the phone number to contact the hospital's team resuscitation team had recently been changed. Also, resuscitation team did not know the number needed to open the new electronic keypad lock on the ward door. Finally, none of the staff on duty that night had been trained in basic life-support techniques. The result was the woman died.

In another case an elderly man received the wrong medication and died. He had been quite healthy, but had the misfortune to be admitted on New Year’s Eve when staff are typically thin on the ground and often made up of temporary staff supplied by agencies.

At least as a result of incidents like the first the NHS has now standardised the emergency number in all hospitals to 222

Thomas poses the question, which hospital would you rather attend. You may feel a 5 per cent rate of medical errors to be "scary stuff." But if the other does not know its error rate you have much more to fear.

According to Thomas you cannot know something is improving if you don’t have reliable quantitative data relating to past and present conditions? "The first step to improving patient safety and knowing we have improved patient safety is the adoption of a common incident classification and reporting system. The mandatory and centralised reporting of all patient safety incidents not only allows us to quantify progress in our “war on error” – but also helps us to identify themes and patterns in the types of errors that are occurring, thus allowing us to propose solutions that can be adopted across the health service, sharing the learning, and preventing future tragedy."

Andy Brazier