Final Report > Chapter 26: The Safety of Care > Designing safer systems, buildings, equipment and pharmaceuticals

Designing safer systems, buildings, equipment and pharmaceuticals

46 By bringing more information about sentinel events into the open, it becomes possible to understand their causes and to act accordingly. Very often the causes can be minimised by designing safer systems and equipment. This approach of looking at systems is exemplified by the reports into an incident in Nottingham in 2001 when a young patient was mistakenly given the drug vincristine by spinal injection. [35] This was a catastrophic clinical error; the patient died two weeks later. The reports considered how the human systems (of staff induction and training) and the equipment used for giving injections, should all be changed across the NHS to reduce substantially the risk of a similar error occurring elsewhere again.

47 In terms of occupational health and safety, the Health and Safety Executive (HSE) has a well-developed system for collecting, analysing and acting on information about unsafe materials or practices. Under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995, all employers are required to report relevant incidents. The incidents are analysed and where patterns emerge, action is taken to improve guidance and to seek changes. One among many examples is the recently produced guidance to safeguard flat-belt conveyors in the food and drink industries. An analysis of accidents caused by machinery in these industries over a ten-year period showed conveyors to be the cause of 30% of injuries investigated by the HSE. The new guidance covers legal requirements for, and safe design of, new conveyors as well as guidance on maintenance for old as well as new machines. [36]

48 During the Inquiry's seminars, we were impressed by the extensive experience of anaesthetists in applying a `systems approach' to safety. The work of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland deserves to be commended. Through their emphasis on protocols and guidelines, and in their influence on the design of equipment, they have helped to make remarkable advances in the safety of anaesthesia over the past 30 years. The field of anaesthetics (and of anaesthesiology in the USA) has led the way in the use of `engineered safety devices', meaning devices that physically prevent errors. One example, quoted in a recent article in the `British Medical Journal', is the system in the operating theatre of gas connectors that are designed so as prevent a gas hose or cylinder from being installed in the wrong site. [37] In healthcare as a whole, however, it is well recognised that the adoption of an approach to solving or addressing specific hazards by designing equipment differently is under-explored. [38] This is to be regretted, given the great pool of knowledge and skill amongst the medical profession and within the NHS. Organisations within the DoH, such as the Medicines Control Agency, the Medical Devices Agency and NHS Estates also have a wide range of experience of the effect of design-led solutions on improving safety and on changing the conditions which give rise to unsafe practices. For the future, therefore, we regard it as of great importance to develop this area of research and development. We take the view that the new National Patient Safety Agency should, as a matter of urgency, bring together managers in the NHS, representatives of the pharmaceutical companies and of the manufacturers of medical equipment, members of the healthcare professions and the public to tackle what are some of the more fundamental and persistent underlying causes of unsafe practices. The aim should be to seek to apply approaches based on engineering and design so as to reduce (and eliminate to the extent possible) the incidence of sentinel events. In this context, we commend in particular the example of the Australian Incident Monitoring Study (AIMS) in anaesthesia, which, since 1998, has held ten national consensus conferences bringing together all interested parties to discuss ways of reducing the rate of adverse incidents in anaesthesia.

Footnotes

[35] Toft B. `External Inquiry into the adverse incident at Queen's Medical Centre Nottingham on 4th January 2001'; and Woods K. `The Prevention of Intrathecal Medication Errors'. NHS Executive, April 2001. Both reports available at www.doh.gov.uk

[36] See HSE Press Release E072:01, 23 April 2001. www.hse.gov.uk/press. The original RIDDOR regulations were made in 1985 and themselves expanded on a form of reporting accidents obligatory in factories before that

[37] Gaba DM. `Anaesthesiology as a model for patient safety in health care'. `BMJ' 2000; 320: 785-8. www.bmj.com

[38] See `An Organisation With a Memory', p. 78