There has been a paradigm shift in terms of thinking about errors. In the aftermath of disasters, the lens of responsibility is being refocused away from people and towards (work) places. Institutions not individuals, processes rather than persons are becoming the focus of investigation. The search for scapegoats is beginning to look crass and ineffective. This is reflected in the formal responses to these events, such as public inquiries, which now routinely focus on system responsibility. Whilst systems analysis has obvious merits it also raises important and unresolved questions. In particular, what are the risks of this shift towards systems thinking? What are the implications for individual professional responsibility? Will the commitment to systems responsibility be meaningful in practice? First, however, we must sketch the contention and connotation of different descriptions of error episodes and appreciate the true toll of the error problem in medicine.
A serious blunder at one of Britain's top fertility clinics dramatically increased the risk its patients would suffer a miscarriage or give birth to a child with serious health problems, sparking fresh fears about how IVF centres are run in the wake of a series of scandals. Unscreened sperm used by staff at the London Women's Clinic (LWC) to create dozens of embryos was later found to have a chromosome abnormality that could have been passed on to any unborn child, The Independent on Sunday has learnt. The British Fertility Society's screening guidelines make it clear that the clinic should never have accepted the donor. At least one couple suffered a miscarriage as a direct result.
Lack of regulation and "professional greed" is putting patients undergoing cosmetic surgery at more risk than ever before, a leading doctor warns. Nigel Mercer, president of the British Association of Aesthetic Plastic Surgeons, called the cosmetic surgery industry an "unregulated mess". Tighter control is needed to clamp down on issues such as two-for-one offers and untested products, he said. His views are backed by several doctors writing in the Clinical Risk journal.
Checklists that spell out exactly how to care for patients with common conditions have dramatically reduced hospital deaths, say doctors. The British Medical Journal reported a 15% fall in the number of people who had died at one north London hospital trust using so-called care bundles. These are checklists covering dozens of conditions including strokes, heart failure and MRSA infections. The researchers said death rates could be "halved" using the system.
This Legal Guidance has been agreed in consultation with the Medicines and Healthcare products Regulatory Agency (MHRA) and the Department of Health (DH). Keir Starmer QC, Director of Public Prosecutions said: "We were made aware of rising concerns among pharmacists' professional bodies in relation to prosecuting offences under the Medicines Act 1968 where a dispensing error has occurred. The MHRA subsequently approached us with a view to creating guidance for prosecutors and we have worked together to reach agreement. "We welcome this cooperation between our departments and believe that this Legal Guidance will ensure high quality decision making and consistency of approach when prosecutors come to consider such cases."
In a recent case in the UK, six men stored their sperm before undergoing chemotherapy treatment for cancer in case they proved to be infertile after the treatment. The sperm was not properly stored and as a result was inadvertently destroyed. The men sued the NHS Trust that stored the sperm and were in the end successful. This paper questions the basis on which the judgement was made and the rationale behind it, namely that the men ‘had ownership’ of the sperm, and that compensation was thus due on the grounds that the men's property had been destroyed.