Headlines: June 14th, 2000

The NHS is going to learn from aviation and other industries’ experience of analysing incidents and ‘near misses’.A panel of experts, including risk assessors from other sectors, has put forward a plan that has been accepted immediately by Chief Medical Officer Liam Donaldson in the light of a succession of scandals involving members of the medical profession.

The new system, will be in place before the end of this year. It is likely to involve a mandatory reporting scheme for adverse health care events and ‘near-misses’, a single database for analysing and sharing lessons from incidents and near misses, including litigation and complaints data, and improved investigation into such incidents. The aim is also to move from a blame culture to a questioning culture which seeks to understand the causes
of failures.

NHS organisations already have incident reporting systems but there is little consistency and no feedback into a single database.

Although obviously influenced by public concern at specific reported incidents which sap public confidence in the NHS, the report is also driven by cost. The legal and compensation costs of medical error are probably around two billion pounds a year.

The expert committee’s report, An Organisation with a Memory, is on the internet at: www.doh.gov.uk.