Identifying system failures by incident reporting systems

Gerald Sendlhofer, 1) Head & 2) Scientific co-worker,
May 12, 2014

With respect to the scientific article of Franklin et al. (BMJ Qual Saf 2014;0:1-8.doi:10.1136/bmjqs-2013-002572) I would like to address two further issues concerning the learning and reporting system in general as well as defense strategies in order to prevent errors in administration of intrathecal chemotherapy.

The amount of nine million incident reports in NHS is very impressive when compared to other reporting systems within European countries. NHS- reports over a period of 11 years implicates that more than 2.000 incidents have to be sent per day by healthcare professionals to the National Reporting and Learnings System (NRLS). According to published data (1) for England and Wales more than 153.000 out of 1.45 million incidents of the type "medication" were reported from Oct 2012 to Sep 2013. Severe harm or deaths were scored in 10.781 cases (0.7% per year). Errors in administration of intrathecal chemotherapy have been reported in 38 times over a decade within NHS. Compared to the German Medicine (2) (between 1995 to 2005 528 suspected adverse concerning vinca alkaloids) or the European Medicine Agency (approximately 350 documented cases), the number of reported events seems low within NHS. Nevertheless, reporting of patient safety incidents is a subjective and voluntarily exercise and on a very high level within NHS.

In many other European countries, homogenous reporting and learning system are lacking so far. In Austria for example, a NLRS is implemented and accessible for the public (3), whereas hospitals run various reporting and learning systems without national coordination and evaluation. Within four years of being online, in total 344 incidents were reported (4 reports per week) to the NLRS and thereof, 21% were scored implicating therapeutic harm.

NHS is in a leading role concerning NRLS and the level of patient safety culture with respect of reporting events as well as their open- minded way in presenting statistics to the public is unique. Concerning the data pool, NHS could support others in the development of guidelines and patient safety practices in order to overcome the most prominent hazards.

The authors presented a comprehensive list of defense strategies to prevent vinca alkaloids errors. Furthermore, we suggest, in line with the Evidence-Based Practice guideline (4), team trainings and in analogy to the WHO-Surgical Safety Checklist a team-time-out before administration of high-risk medication. Author: Name:Dr. Gerald Sendlhofer Title/position: 1) Head 2) Scientific co-worker Affiliations: 1) Department of Quality and Risk Management, University Hospital Graz, Graz, Styria, Austria 2) Division of Plastic, Aesthetic and Reconstructive Surgery, Medical University Graz, Styria, Austria

(1) summaries/?entryid45=135253 (accessed 7 May 2014)

(2) (accessed 7 May 2014)

(3) (accessed 7 May 2014)

(4) Schulmeister L. Preventing vincristine administration errors: does evidence support minibag infusions? dOI: 10.1188/06.CJON.271-273

Conflict of Interest:

None declared

Conflict of Interest

None declared