PATIENT SAFETY

Patient safety: a mapping of the research literature

Background

Patient safety, medical error and adverse event reporting is becoming a major issue in health care systems. It has been estimated that every year, in the NHS, around 400 people die or are seriously injured in adverse events arising from medical devices, and nearly 10,000 people are reported to have experienced serious adverse reactions to drugs. These figures are thought to be an underestimation of the true scale of the problem.

Many of the accidents which take place are reported to be replicas of earlier ones and it appears that the mechanisms for learning from these experiences are absent or could be greatly enhanced. "Building a Safer NHS for Patients" sets out the Government's plans for promoting safety and places patient safety in the context of the quality programme. Before new research is commissioned it is important to have an understanding of the current evidence base around safety in general and patient safety in particular. In addition research from other areas of high-risk activity where risk management strategies are well established, such as aviation and the military, may have a potential application to the NHS.

The aim of this project was to map the research literature in order to advance understanding of the current evidence base around safety in general and patient safety in particular.

Findings

The goals of patient safety research have been diverse. Some studies have evaluated specific interventions, whilst others have had a more general aim of improving patient safety. The study design used across the identified studies varied and was often poorly described; observational studies tended to dominate. Small concentrations of similar studies in the existing research may provide some indicator of direction for future research: computerised or automated systems to control medication errors; education and training programmes, including continuing professional development; attitudes towards errors and barriers to error reporting; organisational factors which affect error. The development and implementation of adverse event reporting systems has become a national priority in the UK and elsewhere. However, current research evaluating their effectiveness is limited and of poor quality. It is difficult to envisage a means of carrying out useful, large-scale research studies to improve patient safety without a reliable method of measuring adverse event rates nationally.

Conducted by: Marie Westwood1, Mark Rodgers1, Amanda Sowden1, Jenny Firth Cozens2, Su Golder1, Julie Glanville1

1. Centre for Reviews and Dissemination; 2. University of Northumbria at Newcastle

Publications

Westwood M, Rodgers M, Sowden A. Patient safety: a mapping of the research literature. York: University of York; 2002

Funding

Commissioned by the Department of Health Patient Safety Research Programme