Maxine offredy, Jacquie Scott, Robert Moore
Background Procedures for reporting ‘near misses’ are well established in many large organisations such as, Shell Petroleumand British Airways, which take a less punitive approach to management error than the British NHS. Recent British government documents along with guidance from the National Patient Safety Agency provide the opportunity forthe reporting and learning from experience of adverse events and near misses within a culture of self-re? ection and appraisal.Objective To report the processes and outcomes of an investigation of an incident involving medical equipment and the recommendations that should improve safety and learning.Methods Structured interviews were conducted with ten health personnel in one primary care trust. Interviews were analysed using the protocol developed by the Clinical Risk Unit and the Association of Litigation and Risk Management, which is basedon Reason’s framework.Results The investigation revealed a number of organisational factors which went unnoticed until the incident occurred. Work environment factors were identiŽ ed both at the speciŽ c and general level. The lack of suitable sta¡, or insu¤cient sta¡ wereidentiŽfied as major concerns. The absence of agreed referral criteria and lack of clarity about responsibilities were identiŽfied as contributory factors to the incident. The transitional and transactional arrangements for moving from a primary caregroup to a primary care trust were also highlighted as contributing to the incident.Conclusions The investigation shows that an adapted human factors methodology can be usefully applied to the health sector to enable managers to understand why events occur and, therefore, removes the emphasis from individual errors. A recommendation from the study is that contractor services and independent practitioners would benefit from the use of the primary care trust’s incident reporting framework.
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