Quality improvement report: Learning from adverse incidents involving medical devices.

ABSTRACT:

Problem

The NHS is perceived to have a poor record of learning from incidents. Despite efforts of the Medical Devices Agency, which issues safety warnings, adverse incidents with medical devices continue to occur, some of which result in serious injury or death through device failures, user errors, and organisational problems.

Design

Introduction of feedback notes on a supportive investigation that seeks to determine latent factors, immediate triggers, causes, and positive actions taken by staff that minimised adverse consequences.

Background and setting

Medical physics department providing equipment management services in a major NHS teaching trust.

Key measures for improvement

Reduction in repetitions of adverse incidents and improved staff competency in usin

SUBMITTER: Amoore J 

PROVIDER: S-EPMC1123780 | biostudies-literature | 2002 Aug

REPOSITORIES: biostudies-literature