One of my research interests is patient safety in primary care. Patient safety incidents are an important and widespread problem in primary care. If we use a common definition of a patient safety incident (any unintended or unexpected incident which could have or did lead to harm for one or more patients) then evidence from the literature suggests that potentially there could be anywhere between 37-600 patient safety incidents per day in the NHS). Fortunately, most of these incidents will have very little consequence – they could be errors of process, for example, a misfiled result, a missing discharge letter from hospital. They could be errors of omission, for example a patient who should be on a drug but isn’t. Or they might be something more serious such as a delayed diagnosis or even a misdiagnosis which may result in harm.
The point is that many things can go wrong in general practice and some of them may have serious consequences. Trying to improve patient safety can be fraught with difficulty. Where does one start?
When things go wrong, there is a tendency to blame people. However, our understanding of patient safety shows us that quick assumptions and routine assignment of individual blame do not get to the heart of the problem. There are many underlying causes which contribute to patient safety problems and in the majority of cases these extend beyond the individual or the team.
To show you what I mean by this, I am going to tell you about a patient safety incident that involved me. Yes, just like anyone else, I can make mistakes and sometimes those mistakes can have serious consequences. The important thing is to be open about what has happened, understand why it happened and make sure that learning takes place…..
(My thanks to my medical student, Javed Naqvi, from UCL who wrote up this incident)