The Establishment of the Clinical Safety Research Unit - An Overview

Background

Several important new initiatives in the last five years underline the increasing attention paid to medical error and patient safety. Studies in the United States , Australia and Britain suggest that 4-16% of patients admitted to acute hospitals are harmed in some way by medical interventions. The recent report of the Institute of Medicine on `Building a Safer Healthcare System' starkly set out the scale of harm of patients and an ambitious and radical agenda for change, which attracted Presidential backing in the United States . In March 2000 British Medical Journal devoted an entire issue to the subject of medical error in a determined effort to move the subject to the mainstream of academic and clinical enquiry. In Britain the Department of Health commissioned a major report `An Organisation with Memory', a report covering similar ground to the Institute of Medicine report, but in a British context. This has been followed, in May 2001, by `Building a safer NHS for patients' which describes the new national incident reporting system and establishes the `National Patient Safety Agency'.

The causes of harm to patients

Human error is routinely blamed for disasters in the air, on the railways, in complex surgery and in healthcare generally. However, quick judgements and routine assignment of blame obscure a more complex truth. While a particular action or omission may be the immediate cause of an incident, closer analysis usually reveals a series of events and departures from safe practice, each influenced by the working environment and the wider organisational context.