Saving lives with better processes

How can a doctor in a small practice with only one or two GPs learn from the mistakes of doctors across the country?4111 In any small practice, there’s a risk that an error can be interpreted as a one-off event, as there is limited awareness that the same incident could be occurring in other practices. However, a study led by Macquarie University GP researcher Associate Professor Meredith Makeham, demonstrated a way to share incident information among a large network of practices. This allowed individual practices to collectively learn from each other. The National Health and Medical Research Council-funded Threats to Australian Patient Safety (TAPS) study collated over 600 anonymous error reports from randomly selected NSW GPs and identified a number of systematic process issues that could put patients at risk. For example, the study identified that the new packaging for a two-component meningococcal vaccine had resulted in some patients being administered just the ineffective liquid component of the vaccine, without the active powder component. “This mistake would be easy to dismiss as human error at each individual practice,” Meredith says. “But the weight of evidence across a large number of practices clearly indicated that there was a systematic problem that needed to be resolved.” In fact, the study found that more than twice as many errors were due to process problems than were due to deficiencies in the knowledge and skills of health professionals. The study’s methods have recently been adopted by the French national quality and safety agency. For more information: Macquarie University Meredith Makeham +61 2 98502322 meredith.makeham@mq.edu.au