Evidence : how safe are clinical systems?

Abstract

‘Rather than being the instigators of an accident, operators tend to be the inheritors of system defects …their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking’ (James Reason, 1990) This study was commissioned by the Health Foundation as part of its work to examine how systems reliability affects patient safety, and how this can be improved. The purpose of the research was to describe the nature, type, extent and variation in the reliability of five healthcare systems that have the potential to cause harm to patients in UK hospitals. These are: the availability of clinical information in outpatient clinics, prescribing for inpatients on hospital wards, clinical handover between doctors, equipment availability in the operating theatre, and systems for inserting intravenous lines. Seven hospitals from across the UK participated in the research. Each clinical system was studied in three hospital organisations. The research began in January 2009 and, including the time taken to gain ethical approval, was completed within a year