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vial of lasix. in his hurry he are you aware of the
selects potassium chloride incident reporting system
and administers it to the at each practice you visit?
“The only person who
patient. the patient dies. reporting when things
What are the “Swiss go wrong is essential, as
never makes mistakes is
cheese” holes in it explores the underlying
the person who never does
this scenario? causes of patient safety
■ Active holes – tired incidents. nHs organisations
anything” – Denis Waitley
doctor, working nights, should have a systematic
third night in a row, approach where staff know
feeling unwell, stressed. what type of incidents to of patient safety incidents So what have
■ latent holes – vials report, what information is received from nHs staff. as we learned?
of medication similar, required and how to learn well as making sure errors are all gps make mistakes,
small writing, stored from them. staff should feel reported in the first place, the hopefully minor ones. What’s
next to each other in they can report incidents npsa is trying to promote important is being honest,
the open containers in without the fear of personal an open and fair culture in owning up and reporting the
the treatment room, not reprimand. a positive patient the nHs, encouraging all mistakes so that lessons
labelled on containers, safety culture is one that has healthcare staff and patients can be learnt. the best gps
poor organisation open communication, mutual to report incidents. openly admit to making
of doctors’ rota. trust, shared perceptions of during the last five years, mistakes and see the process
the importance of safety and the npsa has received more as a learning tool. prepare
incident reporting confidence in the efficacy than 2.7 million reports of yourself by finding out
system of preventative measures. patient safety incidents. the about the reporting system
incident reporting has proved npsa analyses these reports at your practice, and by
to be a useful tool in preventing learning from patient and creates safety alerts reading npsa safety alerts.
error in high-risk industries, safety incidents actions and rapid response patient and staff safety is
such as aviation, nuclear and patient safety incidents need reports. an analysis of patient essential for good quality
petro-chemical industries. it to be shared to prevent them safety incidents reported to care; let’s not forget that
has increased investment in happening again. the national the npsa between July 2007 we are all patients too!
the development of proactive patient safety agency and June 2008 showed Julie Wilson is an
and reactive safety systems. (npsa) was set up in 2001 to that 589,043 incidents were MPS risk manager, with
if an aviation incident occurs co-ordinate efforts to report reported from acute/general more than 20 years’
it is reported, investigated and learn from mistakes. it hospital setting, 73% of the experience tackling risk
and lessons are learnt. collects and analyses reports total received for that period. in health settings.
sessional gp | voluMe 1 | 2009 www.mps.org.uk 25
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