BBC NEWS Americas Africa Europe Middle East South Asia Asia Pacific
BBCi NEWS   SPORT   WEATHER   WORLD SERVICE   A-Z INDEX     

BBC News World Edition
 You are in: Health  
News Front Page
Africa
Americas
Asia-Pacific
Europe
Middle East
South Asia
UK
Business
Entertainment
Science/Nature
Technology
Health
Medical notes
-------------
Talking Point
-------------
Country Profiles
In Depth
-------------
Programmes
-------------
BBC Sport
BBC Weather
SERVICES
-------------
EDITIONS
Thursday, 6 February, 2003, 00:01 GMT
One in three medical errors 'procedural'
Laboratory worker
Ordering the wrong lab tests accounted for some errors
One in three medical errors is due to procedural mistakes such as not ordering the right tests, research has shown.

The five-year Israeli study looked at outpatient care. Most research examines hospital inpatient services.

They looked at the root causes of 1,100 errors which occurred in Macabi Health Services, a non-profit health maintenance organisation (HMO), covering 1.6 million people, between November 1996 and August 2001.

During that period, the HMO ran a risk management system based on the aviation industry's approach to safety.

Ensuring the safety of everyone who comes into contact with health services is one of the most important challenges facing healthcare staff

National Patient Safety Agency spokesman
Under this no-blame system, it is assumed errors usually happen because of faults in the system rather than individual error.

A telephone hotline was set up to encourage staff to report incidents.

A third of the errors or "near-misses" related to procedural errors, such as specialist referrals, ordering laboratory tests and reviewing patients' medical histories.

One in five were about treatment errors, 18% about errors of judgement and 15% about laboratory and imaging test errors.

Communication problems accounted for one in eight mistakes.

Boundaries

After the study, around 470 recommendations were made to change the system in a bid to prevent further errors being made.

Changes included mentioning smoking history on medical records.

The authors, led by Dr Rachel Wilf-Miron of Macabi Health Services, Tel Aviv, said not enough attention has been paid to eradicating errors in outpatient or community care, compared with hospital services.

Writing in the journal Quality and Safety in Health Care, they said: "In hospital care, events are monitored within defined temporal and geographical boundaries, and physicians usually work in teams which mean that, once made, errors are transparent and almost immediately evident to the entire team.

"Alternatively, in community based care an error may not be recognised until long after the medical encounter.

"Moreover, in most ambulatory medical encounters the physician is the sole team member.

"This isolation enables delay or evasion of adverse event reporting and consequently hinders individual as well as organisational learning."

They recommended community services introduce a risk management system, which they said would encourage reporting of errors and near-misses.

Patient safety

A spokesman for the UK's National Patient Safety Agency told BBC News Online: "Ensuring the safety of everyone who comes into contact with health services is one of the most important challenges facing healthcare staff.

"The NPSA, established in 2001, has a key role in implementing the patient safety agenda, and will run a national system for reporting, analysing and learning from adverse events and near misses involving NHS patients."

See also:

18 Jun 02 | Health
18 Nov 02 | Health
05 Dec 02 | Health
02 Mar 01 | Health
Internet links:


The BBC is not responsible for the content of external internet sites

Links to more Health stories are at the foot of the page.


 E-mail this story to a friend

Links to more Health stories

© BBC ^^ Back to top

News Front Page | Africa | Americas | Asia-Pacific | Europe | Middle East |
South Asia | UK | Business | Entertainment | Science/Nature |
Technology | Health | Talking Point | Country Profiles | In Depth |
Programmes