Medical Error and Technologies Research Workshop, London, 3 November 2004

Discussion points summary

v      Conducting research into patient safety

Ø       Problems of data collection and analysis

Ø       The need for a theoretical framework

Ø       Different theories of error.  What is an error?

Ø       Patient perspective. Are patients represented in the research on patient safety and medical errors? How should they be involved?

Ø       Ethical and legal issues of conducting research in the area of patient safety. The tension between researchers’ duty to patients and to the research subjects.

Ø       The evolving role of ethic committees and their rules

v      Defining errors

Ø       Different types of errors. Problem areas (e.g. prescribing errors in paediatrics).

Ø       What is an error and what is ‘normal practice’. When does variability of practice become an error? How is the definition of error evolving?

Ø       What are the attitudes to errors? Studies indicate that different people (e.g. clinicians and pharmacists) pick up different errors from notes. This suggests that different and professional groups might define prescribing errors differently.

Ø       Reporting errors

Ø       Managing errors and news about errors 

v      Ethics, law and society

Ø       Culture, legal matters and litigation. The tension between the culture of increased litigation and the aim of openness and ‘blame free’ reporting. How is the culture changing and how might it effect self-reporting of errors and the research in the area?

Ø       Controversies in prescription, regulation and use of certain drugs

v      ‘Learning organisations’

Ø       How we can learn from each other? There is a need for feedback

Ø       How errors should be reported and to whom?

v      Role of pharmacists

Ø       New reporting practices may change the way pharmacists are perceived.

Ø       The tension between pharmacists’ role as ‘part of the team’ and as ‘pharmacy police’

v      Computerised systems

Ø       Advantages and disadvantages

Ø       Specialised/bespoke systems versus general systems. Tension between the need for systems that respond to local needs and the need for compatibility and universality of systems across the NHS

Ø       Design of systems and electronic reporting.

Ø       Evaluation of computerised systems. Different attitudes to evaluating drugs, medical technology and information technology. It seems that there is less emphasis on evaluating IT

v      The implications of  the National Programme for Information Technology