TAYSIDE PATIENTS are being encouraged to speak up and help prevent serious incidents or “near misses” that could adversely affect their health, writes Marjory Inglis, health reporter.

At the same time local health staff are being encouraged to be open and honest about things that go wrong, identifying “untoward incidents” quickly without fear of blame, to then make positive changes and avoid incidents being repeated.

In busy hospital wards and health centres complex problems can conspire to cause what are known as “adverse events”.

In the past a surgeon in Dundee mistakenly amputated a perfectly good limb and the patient then had to undergo a further operation to take off the bad leg.

People have been given the wrong dose of a drug or drugs destined for another patient—any number of things can go wrong.

NHS Tayside’s head of risk management Pat O’Connor said yesterday that when something goes wrong, all that most patients want to know is that the same thing won’t happen to someone else.

She said the local population could be assured the region had one of the best risk management systems, constantly monitoring and trying to reduce risk.

Health organisations throughout the UK and beyond were keen to find out about the Tayside way of doing things.

Instead of trying to track down individuals and mete out blame, she said NHS Tayside was trying to promote a “culture of prevention” that would help staff learn from “adverse events and near misses”.

The number one priority was avoiding things going wrong or nearly going wrong, by having a long hard look at “adverse incidents” and near misses and changing the things that created an environment where problems might occur.

“National figures show that one in 10 patients suffer an adverse event at the hands of medical staff,” said Mrs O’Connor.

“Clinical error is the third most frequent cause of death in Britain.

“If we focus on people (look for someone to blame) and say ‘don’t do it again’, it only makes the situation worse. They are so intent on trying to not make a mistake that they make lots.

“We need to get people to record mistakes and near misses, look at why the mistake has been made and support them to change their systems and ways of working to try to ensure the same mistake doesn’t happen again.”

She explained that “near misses” happen without ever affecting the patient.

The patient may have been on the verge of being given, for example, the wrong drug or the wrong dose of a drug, when someone steps in and points out the mistake.

“We need to get underneath why that nearly happened,” said Mrs O’Connor.

“Is it a training issue, an equipment problem, or what?”

But she said one of the simplest ways of ensuring medical mistakes don’t happen is to get patients themselves involved.

“I want the local population to get involved,” said Mrs O’Connor.

“They can say ‘hey, that’s not the tablets I get. I take a pink one in the morning and a blue one in the afternoon.’ That’s another way patients can help us.”

The reporting of adverse events, which are recorded and reviewed, goes on continuously but a fully electronic version of the system “went live” in Tayside only last month.

Mrs O’Connor said a “robust system” to learn from adverse events was in operation in Tayside.

In-depth reviews were undertaken to highlight where improvements could be made to prevent errors recurring.

To encourage staff to get involved in reporting and learning from mistakes and near misses NHS Tayside, in conjunction with a pharmaceutical company, is running a competition for people who best explain what they’ve learned from an adverse event and how they have changed their practise and shared their results with others.

A poster exhibition of the best examples is to be mounted in NHS Tayside headquarters, Kings Cross Hospital, Dundee, at the end of the month, when a winner will be selected.

“Somebody said to me, ‘you are rewarding people for making mistakes’,” said Mrs O’ Connor.

“We are not doing that. We are rewarding people for learning, for taking the initiative and preventing more harm.”