Improving safety and learning: case study of an incident involving medical equipment

Offredy, Maxine PhD MPhil BA (Hons) RN
Scott, Jacquie BEd (Hons) DipN RN
Moore, Robert MBA

Senior Lecturer, Faculty of Health and Human Sciences, University of Hertfordshire, Hatfield, UK
Director of Clinical Governance and Nursing
Director of Primary Care
Harrow Primary Care Trust, Harrow, UK

ADDRESS FOR CORRESPONDENCE

Dr Maxine Offredy, Faculty of Health and Human Sciences, University of Hertfordshire, College Lane, Hatfield, Herts AL10 9AB, UK. Tel: +44 (0)1707 284439; fax: +44 (0)1707 285299; email: [email protected]

Accepted 9 October 2003

Quality in Primary Care 12(1):p 19-27, 2004.

Background

Procedures for reporting ‘near misses’ are well established in many large organisations such as, Shell Petroleum and British Airways, which take a less punitive approach to management error than the British NHS. Recent British government documents along with guidance from the National Patient Safety Agency provide the opportunity for the reporting and learning from experience of adverse events and near misses within a culture of self-reflection and appraisal.

Objective

To report the processes and outcomes of an investigation of an incident involving medical equipment and the recommendations that should improve safety and learning.

Methods

Structured interviews were conducted with ten health personnel in one primary care trust. Interviews were analysed using the protocol developed by the Clinical Risk Unit and the Association of Litigation and Risk Management, which is based on Reason’s framework.

Results

The investigation revealed a number of organisational factors which went unnoticed until the incident occurred. Work environment factors were identified both at the specific and general level. The lack of suitable staff, or insufficient staff were identified as major concerns. The absence of agreed referral criteria and lack of clarity about responsibilities were identified as contributory factors to the incident. The transitional and transactional arrangements for moving from a primary care group to a primary care trust were also highlighted as contributing to the incident.

Conclusions

The investigation shows that an adapted human factors methodology can be usefully applied to the health sector to enable managers to understand why events occur and, therefore, removes the emphasis from individual errors. A recommendation from the study is that contractor services and independent practitioners would benefit from the use of the primary care trust’s incident reporting framework.