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Quality and Safety in Health Care 2002;11:108; doi:10.1136/qhc.11.1.108
Copyright © 2002 by the BMJ Publishing Group Ltd.
Qual Saf Health Care 2002;11:108
© 2002 Quality and Safety in Health Care

Action points

Tim Albert

Compiled by Tim Albert

Q: How can we use mistakes to improve health care?

Two British psychologists gave 315 health professionals a number of short scenarios describing various errors and asked them how likely they were to report each incident.

  • All were reluctant to report adverse events to a superior.
  • Doctors were more reluctant to report them than nurses or midwives.
  • All were more likely to report them when a protocol had been violated and the outcome had been bad.


The authors conclude that the NHS should look to other organisations, such as Shell Petroleum and British Airways, where more proactive systems of error management are used.

See page 15

"The importance of using all types of error to bring about safer care needs emphasising to staff, but this can only be done in an atmosphere of trust" (commentary, page 7)

{blacktriangleright} ACTION POINT

The current system of reporting mistakes in the NHS is ineffective, mistakes go unreported: change is needed.

Q: How can we stop people leaving out important steps in complicated tasks?

The most common source of . . . [Full text of this article]


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This article has been cited by other articles:

  • Gawron, V. J., Drury, C. G., Fairbanks, R. J., Berger, R. C. (2006). Medical Error and Human Factors Engineering: Where Are We Now?. American Journal of Medical Quality 21: 57-67 [Abstract]  

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