1.1 Patient Safety
Although large numbers of people continue to be successfully cared for and treated in the National Health Service, a significant number of errors and other forms of harm occur. It has been calculated that up to 10% of patients admitted to NHS hospitals are subject to a patient safety incident and that up to half of these incidents could have been prevented ((Osborn and Williams, 2004; Vincent et al., 2001). Surprisingly, up to half of the 10% of Iatrogenic or accidental errors could have been prevented (Michell et al, 2012). It was estimated by a Bristol Royal Infirmary Inquiry (Bristol HMSO, 2001) that around 25,000 preventable deaths occur in the NHS each year due to patient safety incidents. These incidents also generate a significant financial burden that includes avoidably prolonged care, additional treatment and litigation costs.
Avoidable unintended or accidental outcomes of medical care, medical errors are also a serious and challenging issue in many other countries including North America. The influential Institute of Medicine‘s (IOM‘s) report, To Err Is Human highlighted the extent of the problem and the need for remediation was documented in Building a Safer Health System (1999), where between 44,000 and 98,000 people die in hospitals each year as the result of medical errors. There is broad international agreement on the importance of achieving improvements to quality in this area (Milligan, 2007). The recorded event where an error is noticed ie a safety incident is defined by the National Patient Safety Agency (NPSA, 2004) as: any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS funded care‘‘. These types of incidents are also referred to in the literature as adverse events/incidents, medical error, clinical error, and include the concept of near miss. The latter is a situation in which an error or some other form of patient safety incident is averted, such as noticing and therefore avoiding giving the wrong drug to a patient.
In the UK, the terminology for self-inflicted errors by clinicians and health workers has evolved from serious untoward incident to ‘significant event’ or in extreme cases ‘never events’ with examples of over 1600 serious incidents occurring in one NHS region in one single year (Rosenorn-Lanng, 2014)
However, whatever the terminology these events are all dependent on the human in the room and in the loop, clearly driving the need to understand the human as a source of error. The study of the effect of the human condition on safety events and human errors is often termed ‘human factors’ and is clearly important in the understanding of safety problems since the care and intervention activities are primarily human driven.