The National Patient Safety Agency (NPSA) was established in July 2001 to co-ordinate the reporting of patient safety incidents and to learn from these incidents in order to improve patient safety in the NHS. The agency has now issued new
guidelines on the importance of wristband use by hospitals after receiving 24,382 reports of patients being mismatched with their care between February 2006 and January 2007. Patient safety could be greatly improved if the use and design of wristbands was standardised by hospitals.
Wristbands are important when patients are unable to identify themselves, or the treatment they should receive because they are critically ill, unconscious or unable to communicate. Errors identified by the National Audit Office (NAO) in their 2005 report
A safer place for patients: learning to improve patient safety, included patients being given the wrong surgery, medication or tests with life-threatening consequences. In 2005 the NAO reported that nearly a million errors or safety lapses has occurred in the previous year, causing 2,000 deaths. Many of these deaths could have been avoided if staff had learnt from previous mistakes.
Writing in the
British Medical Journal in 1983 Neil McIntyre and Karl Popper said that 'it is human to err' but that 'our new principle must be to learn from our mistakes so that we avoid them in future...errors should not be concealed since, after discussion and analysis, change in practice may prevent their repetition.' Lawyers in the clinical negligence department at Leigh Day & Co are fully aware of the sometimes dreadful consequences that mistakes made by medical and other health care staff can have on the lives of their patients.
Anne Winyard, joint head of the clinical negligence department, comments:
'We all make mistakes. But because of the work that doctors, nurses and other health care workers are engaged in, the consequences of their mistakes can be catastrophic for the health of others. Karl Popper's remarks made over 20 years ago are still very relevant today – relevant to law and other walks of life as well as to medicine, and relevant to basic issues like design and use of wristbands as well as more complex situations. If we can learn from our mistakes, we can save others and ourselves from the effects of their repetition. You cannot learn from mistakes that are hidden or swept under the carpet. So it is important that guidelines not only foster best practice, but also encourage openness and honesty about mistakes. As Neil McIntyre and Karl Popper said, ‘hiding mistakes must be regarded as a cardinal sin’, because then we are doomed to repeat our mistakes.’
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