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There is a large body of research to suggest that serious errors are widespread throughout medicine. The traditional response to these adverse events has been to adopt a 'person approach' - blaming the individual seen as 'responsible'. The culture of medicine is highly complicit in this response. Such an approach results in enormous personal costs to the individuals concerned and does little to address the root causes of errors and thus prevent their recurrence. Other industries, such as aviation, where safety is a paramount concern and which have similar structures to the medical profession, have, over the past decade or so, adopted a 'systems' approach to error, recognizing that human error is ubiquitous and inevitable and that systems need to be developed with this in mind. This approach has been highly successful, but has necessitated, first and foremost, a cultural shift. It is in the best interests of patients, and medical professionals alike, that such a shift is embraced in the NHS. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to evaluate the common themes leading or contributing to clinical incidents in a UK teaching hospital., Design/methodology/approach: A root-cause analysis was conducted on patient safety incidents. Commonly occurring root causes and contributing factors were collected and correlated with incident timing and severity., Findings: In total, 65 root-cause analyses were reviewed, highlighting 202 factors implicated in the clinical incidents and 69 categories were identified. The 14 most commonly occurring causes (encountered in four incidents or more) were examined as a key-root or contributory cause. Incident timing was also analysed; common factors were encountered more frequently during out-hours--occurring as contributory rather than a key-root cause., Practical Implications: In total, 14 commonly occurring factors were identified to direct interventions that could prevent many clinical incidents. From these, an "Organisational Safety Checklist" was developed to involve departmental level clinicians to monitor practice., Originality/value: This study demonstrates that comprehensively investigating incidents highlights common factors that can be addressed at a local level. Resilience against clinical incidents is low during out-of-hours periods, where factors such as lower staffing levels and poor service provision allows problems to escalate and become clinical incidents, which adds to the literature regarding out-of-hours care provision and should prove useful to those organising hospital services at departmental and management levels.

Purpose: The aim of this paper is to generate a debate regarding the value of incident reporting in the UK., Design/methodology/approach: This paper critiques the dominant approach to patients in the UK., Findings: It is suggested that the reliability of health care processes would need to substantially improve before an incident reporting system can have a meaningful impact on patient safety., Practical Implications: Greater benefits in patient safety will be accrued by focusing resources on designing reliable processes rather than the extension of incident reporting., Originality/value: This paper offers a local perspective on a potentially flawed national strategy.

There is a large body of research to suggest that serious errors are widespread throughout medicine. The traditional response to these adverse events has been to adopt a 'person approach' - blaming the individual seen as 'responsible'. The culture of medicine is highly complicit in this response. Such an approach results in enormous personal costs to the individuals concerned and does little to address the root causes of errors and thus prevent their recurrence. Other industries, such as aviation, where safety is a paramount concern and which have similar structures to the medical profession, have, over the past decade or so, adopted a 'systems' approach to error, recognizing that human error is ubiquitous and inevitable and that systems need to be developed with this in mind. This approach has been highly successful, but has necessitated, first and foremost, a cultural shift. It is in the best interests of patients, and medical professionals alike, that such a shift is embraced in the NHS.

In August 1999 the Government set a national objective of reducing the numbers of children acquiring human immunodeficiency virus (HIV) infection from their mothers by 80%. The key policy change towards achieving this objective was that HIV testing was to be recommended as a routine and integral part of antenatal care. The UK has fallen behind other Western industrialized countries in the uptake of antenatal testing and reduction in mother-to-child transmission. This article examines the background to these new recommendations, the substantial benefits of available interventions and the reasons why current testing policies have been failing.