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5. The extent and causes of failure

In many service industries such as aviation, mining and nuclear power, safety is an established priority and considerable investment is made to regulate safety requirements.

In the healthcare sector, however, there has been little information until recently about how commonly things go wrong, both in the UK and abroad. Recent research in the US, Australia and the UK suggests that mistakes may actually be more common than previously realised. It is estimated that:

  • Around one in 10 patients admitted to hospital suffer an adverse event
  • Some 850,000 such events occur each year in NHS hospitals
  • Around half of that total may be avoidable

Eight per cent of adverse events may result in death and six per cent in permanent disability, amounting to over 34,000 preventable deaths and 25,000 preventable permanent disabilities every year

Compensation for clinical negligence costs the NHS more than £400 million a year and outstanding claims for clinical negligence total over £2.4 billion annually

Proportion of inpatient episodes that lead to unintended harm

  • Australia 16.6% (2)
  • United States 3.7% (1)
  • Untied Kingdom 10% (3)

Harvard Medical Practice Study, 1991. 2. Quality in Australia healthcare study, 1995. 3. Vincent et al

The system approach
There are two ways of viewing human error: the person-centred and the system approach. The former focuses on individual factors such as carelessness, inattention or forgetfulness. Organisations may choose disciplinary procedures to try to prevent mistakes in the future which aim to 'name and shame' those involved in the accident. Yet, this makes it hard to view an accident in context and may mean that recurrent problems are not identified.

The system approach recognises that human error is inevitable but the likelihood of such errors occurring can be reduced by changing the work environment. When an adverse event occurs, the important issue should be not who made the error, but how and why a system that should safeguard patients has failed. For example, there may be flaws in the design of a system that can go unnoticed for years, or management decisions such as funding cuts that result in more pressure on staff and the increased likelihood of errors.

In any complex system like the NHS, human error is inevitable and a programme to improve safety for patients cannot eliminate mistakes completely. But the NHS can reduce their occurrence, minimise the impact on the patient when they happen and learn from mistakes so that risk to future patients is reduced.

'Human beings make errors because of the processes that they are functioning in: defective systems make errors more likely'

Dr Lucian Leape, the President's Commission on Consumer Protection and Quality in Health Care in the US, 1997

Learning from other industries
Healthcare is not unique. There are many parallels with other sectors, such as the aviation and nuclear industries. Research and best practice experience have shown that improvements come from understanding the conditions that cause errors. In many cases there is a complex set of interactions between different factors before the event, rather than any single causal factor.

For example, the aviation industry has invested considerable resources into developing systems to gather and analyse information to ensure that lessons are learnt. The Aviation Safety System operates internationally and has five main features:

Accident and serious incident investigations, governed by the International Convention on International Civil Aviation (ICAO) Accidents/ Incident Data Reporting Programme (ADREP). This includes international dissemination of investigation reports.

The Mandatory Occurrence Reporting Scheme (MORS), which provides a mechanism for notifying and reporting a range of adverse events , whether or not they result in an accident. MORS feeds into a national database to analyse trends and provide feedback to the industry.

The Confidential Human Factors Incident Reporting Programme (CHIRP), is administered by an independent body and provides sensitive follow-up and feedback on reports of human errors, which all  remain anonymous.

Company safety information systems, such as British Airways' BASIS system, which record all levels of safety-related incidents. Information is shared on a peer basis and staff feel free to report errors knowing that no individual will be pursued for an honest mistake.

Operational monitoring systems monitor crew competency through regular checks and review of Flight Data Recorder information from every flight. There is management and union agreement on the handling of any incidents or failures detected using this system.

In co-operation with the Clinical Governance Support Team, a group of pilots and doctors is running a team skills programme for the NHS. The programme is called Team Resource Management (TRM) and is based on the aviation industry's mandatory training in crew resource management.

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