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 using devices.

Strategy for change: A feedback note was developed to describe the incident and generic details of the equipment, summarise the investigation (focusing on latent causes and immediate triggers), and describe lessons to be learnt and positive actions by staff.

Effects of change: Feedback notes have been used in teaching sessions and given to ward link nurses. Despite being new, the positive supportive approach has encouraged an open reporting culture.

Lessons learnt: Adverse incidents are typically caused by alignment of different factors, but good practice can prevent errors becoming incidents. Careful analysis of incidents reveals both the multifactorial causes and the good practices that can help minimise repetitions.

Figure

A near miss involving a medical device, and lessons learnt (adapted from Reason5)