http://news.bbc.co.uk/1/hi/health/3840257.stm

Doctors 'not reporting errors'
Over 80% of doctors have seen colleagues make mistakes or had
concerns about the care being provided, a survey suggests.
But Doctors.net.uk found only 15% of incidents which could have led
to death or disability were reported.

The National Patient Safety Agency is rolling out an anonymous
reporting system across the NHS this year.

But the majority of the 2,500 doctors surveyed backed an independent
internet site to log such errors.

Blame culture

Of those questioned, 81% said they did not trust their NHS Trust or
the Department of Health to a run a blame-free system for reporting
their mistakes.

Dr Neil Bacon, founder of Doctors.net.uk, said: "Existing systems
are not trusted by doctors.

"It's meant to be confidential but the culture of no blame isn't a
reality in the NHS. It's used as a witch-hunt.


"Any system that helps prevent medical mistakes, by helping doctors
come forward without the fear of being blamed, would hold real
benefits for the NHS"
Michael Wilks, chairman of the British Medical Association's Medico-
Legal Committee


"At the moment we have no way of learning as doctors from each
other. Effectively, we are all working in the dark."

Dr Bacon said the only way forward was an anonymous system like
those used by airline pilots.

This could be a confidential system on the Internet, he said.

"Doctors want this to change. It isn't doctors being secretive,"
said Dr Bacon.

He said errors reported ranged from small, day in day out mistakes
in prescribing and diagnosing to rare but much more serious
mistakes.

"Doctors across the UK have shown a remarkable honesty and frankness
about the scale of the problem and a demand that things change for
the benefit of their patients," he said.

Time for change

Sue Osborn, Joint Chief Executive of the National Patient Safety
Agency which is introducing the NHS's reporting system said: "If we
want to maximise the numbers of reports we receive and the amount we
learn, we need the trust of clinicians.

"This is why we have developed an anonymous system that will respect
the confidentiality of those who take the time to report to us," he
said.

Michael Wilks, chairman of the British Medical Association's Medico-
Legal Committee, said: "The BMA would welcome a system of reporting
that allows clinical mistakes to be openly discussed and analysed.

He said: "Many medical mistakes are a result of system errors rather
than the negligence of an individual doctor and so any system that
helps prevent medical mistakes, by helping doctors come forward
without the fear of being blamed, would hold real benefits for the
NHS.

"E-learning systems that allows for reporting medical mistakes
should be introduced as part of the planned reform of the clinical
negligence system if it is to effectively tackle the blame culture
within the NHS," he said.

Systems exist

Mr James Johnson, chairman of the British Medical Association,
said: "Doctors are human and therefore inevitably they will
sometimes make mistakes. It is vitally important we learn from these
mistakes.

"If you can find out why something has gone wrong and share that
information you can stop it happening again. But others can best
learn from your mistakes if you have a no blame culture.

"There is already a system in place for sharing information about
medical errors and near-misses - it's called the National Patient
Safety Agency.

"People can report incidents to the Agency on an anonymous basis if
they want to, or can give fuller details. The important thing is to
alert everyone to a problem area so that patients are safeguarded in
future," he said.

The Royal College of Nursing released new guidelines last week aimed
at cutting blood transfusion errors.

It sets out practical step-by-step advice for nurses involved in the
transfusion process.

Figures from the Serious Hazards of Transfusion reporting scheme
show a 47% increase in reporting of adverse events and near misses
since 1996.

Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/1/hi/health/3840257.stm