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Clinical Risk Management.
  1. Fiona Davidson
  1. Department of Genitourinary Medicine, St George's Hospital, London SW17 0QT

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    2nd ed. Ed Charles Vincent. Pp 583; £47.50. London: BMJ Books, 2001. ISBN 0727913921.

    It is a fact of life that people make mistakes. In the NHS the cost of human error runs into billions of pounds a year through lost bed days and the consequences of serious litigation. More importantly, errors distress and harm patients, undermining their confidence in the organisation and their doctors.

    The natural approach to discovering any error is to apportion blame, with its associations of moral weakness. But error management that focuses on any one individual's lapses and mistakes will not reduce the incidence of error. In the short term a scapegoat may be convenient, but measures to reduce mistakes need to aim at redesigning systems so that they are acknowledged, detected, intercepted, and mitigated.

    Highly reliable organisations, such as nuclear power plants and airlines, have a less than the expected number of accidents because they recognise human frailty. Errors are seen as consequences rather than causes. These organisations concentrate on the conditions under which individuals work and try to build defences averting errors before they happen or reducing their effects. Their motto has to be “Safety is everyone's responsibility.”

    The focus of any organisation exposed to risk, including the NHS, therefore, needs to be on the constant possibility of failure and how to prevent it. The second edition of Clinical Risk Management, edited by Charles Vincent, addresses in detail this problem. It covers the evolution of risk management, its expansion beyond its roots in litigation, and the benefits reaped from the study of safety in high risk organisations. His aim is to highlight the need for clinical risk management to focus on patient safety and quality of care, and not on simplisitic prevention of litigation. It is a practical book full of illustrations of how errors arise, risk, and the good and bad management of their consequences.

    The book is divided into four parts. The first, on the principles of risk management, contains a particularly revealing chapter by James Reason, “Understanding adverse events: the human factor.” It opens the theme around which the book is constructed, the interrelation between the individual and the organisation. In the second part, “Reducing risks in clinical practice,” the authors discuss and illustrate the circumstances which lead to errors and accidents that are inherent in specific “high risk” specialties, such as obstetrics and anaesthetics. Part III, “Conditions of safe practice,” discusses the relationship between patient and staff, organisation and environment—for example, in work overload, fatigue, and training. Part IV, “The implementation of risk management” describes the importance of “no blame” culture of reporting incidents, investigating and analysing errors, and of the manner in which adverse events are handled. Included in the chapter are two aspects of error management often overlooked—continuing patient care and support of the staff involved.

    This is an important, well written, readable book which all involved in clinical care should keep on their desks, not on the bookshelf.

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