Reducing error, improving safety

摘要: Editor—It was brave to devote a whole issue medical error1—how recognise, how investigate, analyse, and change systems improve patient safety.1 However, we regret that the edition dominated by American studies, ignoring British contribution of confidential inquiries analyses closed claims, which have significantly improved safety in some well defined areas practice. In United States insurance industry provided impetus for study adverse events,2 Australia government funded similar study3 because it considering “no fault” compensation.3 In Kingdom, 25 years Department Health has financed all successful claims against NHS hospitals their staff. As result need take beyond pilot phase may not be supported.4 Be as may, an important addressed BMJ. Behind each event there is patient, doctor, doctor-patient relationship. A must told when things gone wrong. Every effort made minimise after effects, including financial compensation where necessary. Most patients wish know detail what happened being done reduce possibility recurrence. And members healthcare teams mechanisms come terms with fallibility. It hoped clinical governance will make difference. Meanwhile ethos practice required, this end Action Victims Medical Accidents set up group doctors. often regarded dealing solely litigation, but its raison d'etre always been care. In February year doctors' met informally discuss best translate into General Council's requirements “good go wrong.”5 We are determined our discussion forward would welcome input from others who see defensive exclusive culture medicine. Doctors like involved should contact Dr Anne Savage, acting secretary group.