PERSPECTIVE
Patient safety
Patient safety alerts: a balance between evidence and action
Department of Biosurgery and Surgical Technology, Imperial College London, St Mary’s Hospital, London W2 1NY, UK; c.vincent@imperial.ac.uk
Correspondence to:
Correspondence to:
Dr Vincent
Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St Mary’s Hospital, Praed Street, London W2 1NY, UK; c.vincent@imperial.ac.uk
A perspective on the article by Freer and Lyon (see page327)
Keywords: safety; risk management
| The first 150 words of the full text of this article appear below. |
The scale of harm from health care has been documented for over 150 years, but only in the last decade has there been any sustained interest in systematically examining safety issues. The principal theme of the first major report on safety in the NHS, An organisation with a memory,1 was that health care in general, and the NHS in particular, was extraordinarily poor at learning from mistakes and disasters. One of the most striking instances of this failure was that, between 1985 and 2000, there had been at least 13 documented instances of death from the spinal injection of cytotoxic drugs in the NHS. The circumstances were remarkably similar in all cases; warnings on labels and reports in the medical literature had been insufficient to avert this series of tragedies. We now know events of this kind are far from rare. Studies in several countries have generally
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