Netherlands plans system for reporting errors
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《英国医生杂志》
The Netherlands is set to follow Denmark and the United Kingdom in introducing a national system for blame free reporting of medical errors. The Dutch Healthcare Inspectorate argues in its annual report for 2003 that systematic reporting would improve the safety of patients but requires a cultural change.
Under the proposed system, staff who made mistakes, provided they were not grossly negligent, would be protected from being prosecuted by their employers, the inspectorate, or the criminal courts. Their names would not be made public, although they might be supplied to the people running the system.
Last year 2642 medical errors were reported to the inspectorate, slightly fewer than in 2002. Of these 164 resulted in injury or death. But the inspectorate fears that these are just "the tip of the iceberg" and claims "systematic underreporting." It estimates that avoidable medical errors account annually for between 1500 and 6000 deaths, far more than the 1100 people killed on the roads, for example.
The healthcare inspector general, Herre Kingma, who is a former cardiologist, said: "We must adopt a system of blame free reporting of avoidable, not culpable, mistakes. Fear of being dragged before a medical disciplinary board must not be an impediment."
He gave as an example the hypothetical case of a nurse with 23 years of faultless service who makes a fatal error by mistakenly using an ampoule of kalium (Dutch for potassium) instead of an ampoule of valium. He suggested that it would be more useful to investigate how the error occurred than to punish the nurse by taking her job away.
But he stressed that the system would not be a licence for careless work. "Culpable mistakes arising from laziness, lack of authority, or incompetence should always be reported . We can then deal with them."
The inspectorate believes that a national system of gathering, registering, and analysing data on mistakes and near misses could result in lessons being learnt.(Tony Sheldon)
Under the proposed system, staff who made mistakes, provided they were not grossly negligent, would be protected from being prosecuted by their employers, the inspectorate, or the criminal courts. Their names would not be made public, although they might be supplied to the people running the system.
Last year 2642 medical errors were reported to the inspectorate, slightly fewer than in 2002. Of these 164 resulted in injury or death. But the inspectorate fears that these are just "the tip of the iceberg" and claims "systematic underreporting." It estimates that avoidable medical errors account annually for between 1500 and 6000 deaths, far more than the 1100 people killed on the roads, for example.
The healthcare inspector general, Herre Kingma, who is a former cardiologist, said: "We must adopt a system of blame free reporting of avoidable, not culpable, mistakes. Fear of being dragged before a medical disciplinary board must not be an impediment."
He gave as an example the hypothetical case of a nurse with 23 years of faultless service who makes a fatal error by mistakenly using an ampoule of kalium (Dutch for potassium) instead of an ampoule of valium. He suggested that it would be more useful to investigate how the error occurred than to punish the nurse by taking her job away.
But he stressed that the system would not be a licence for careless work. "Culpable mistakes arising from laziness, lack of authority, or incompetence should always be reported . We can then deal with them."
The inspectorate believes that a national system of gathering, registering, and analysing data on mistakes and near misses could result in lessons being learnt.(Tony Sheldon)