Access

You are not currently logged in.

Access your personal account or get JSTOR access through your library or other institution:

login

Log in to your personal account or through your institution.

If You Use a Screen Reader

This content is available through Read Online (Free) program, which relies on page scans. Since scans are not currently available to screen readers, please contact JSTOR User Support for access. We'll provide a PDF copy for your screen reader.

Quality Improvement Report: Learning From Adverse Incidents Involving Medical Devices

John Amoore and Paula Ingram
BMJ: British Medical Journal
Vol. 325, No. 7358 (Aug. 3, 2002), pp. 272-275
Published by: BMJ
Stable URL: http://www.jstor.org/stable/25451989
Page Count: 4
  • Read Online (Free)
  • Subscribe ($19.50)
  • Cite this Item
Since scans are not currently available to screen readers, please contact JSTOR User Support for access. We'll provide a PDF copy for your screen reader.
Quality Improvement Report: Learning From Adverse Incidents Involving Medical Devices
Preview not available

Abstract

Problem The NHS is perceived to have a poor record of learning from incidents. Despite efforts of the Medical Devices Agency, which issues safety warnings, adverse incidents with medical devices continue to occur, some of which result in serious injury or death through device failures, user errors, and organisational problems. Design Introduction of feedback notes on a supportive investigation that seeks to determine latent factors, immediate triggers, causes, and positive actions taken by staff that minimised adverse consequences. Background and setting Medical physics department providing equipment management services in a major NHS teaching trust. Key measures for improvement Reduction in repetitions of adverse incidents and improved staff competency in using devices. Strategy for change A feedback note was developed to describe the incident and generic details of the equipment, summarise the investigation (focusing on latent causes and immediate triggers), and describe lessons to be learnt and positive actions by staff. Effects of change Feedback notes have been used in teaching sessions and given to ward link nurses. Despite being new, the positive supportive approach has encouraged an open reporting culture. Lessons learnt Adverse incidents are typically caused by alignment of different factors, but good practice can prevent errors becoming incidents. Careful analysis of incidents reveals both the multifactorial causes and the good practices that can help minimise repetitions.

Page Thumbnails

  • Thumbnail: Page 
272
    272
  • Thumbnail: Page 
273
    273
  • Thumbnail: Page 
274
    274
  • Thumbnail: Page 
275
    275