Setting up a database of medical error in general practice: conceptual and methodological considerations.

Though common and the cause of much morbidity and health cost, medical error has until recently attracted little attention from primary care workers. A database that logs medical error, operating within the context of clinical governance initiatives at the level of Primary Care Groups, could provide an appropriate framework within which to scrutinise and identify systematic organisational features associated with risk of serious adverse events. This paper discusses some of the key conceptual and methodological issues that need to be resolved before such a database can be implemented in general practice and considers these deliberations in the light of the Chief Medical Officer for England's recent report, An organisation with a memory.

[1]  Wu,et al.  Medical error: the second victim , 2000, The Western journal of medicine.

[2]  R. Helmreich On error management: lessons from aviation , 2000, BMJ : British Medical Journal.

[3]  L L Leape,et al.  Preventing medical injury. , 1993, QRB. Quality review bulletin.

[4]  T. Brennan,et al.  Incidence of adverse events and negligence in hospitalized patients. , 1991, The New England journal of medicine.

[5]  R. Baker Learning from complaints about general practitioners , 1999, BMJ.

[6]  N. Laird,et al.  Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention , 1995 .

[7]  M R Cohen,et al.  Why error reporting systems should be voluntary , 2000, BMJ : British Medical Journal.

[8]  S. Cembrowicz A national database of medical error , 2000, Journal of the Royal Society of Medicine.

[9]  B. Hurwitz,et al.  A national database of medical error , 1999, Journal of the Royal Society of Medicine.

[10]  Charles Vincent,et al.  Risk, safety, and the dark side of quality. , 1997 .

[11]  L. Andrews,et al.  An alternative strategy for studying adverse events in medical care , 1997, The Lancet.

[12]  T. Brennan,et al.  INCIDENCE OF ADVERSE EVENTS AND NEGLIGENCE IN HOSPITALIZED PATIENTS , 2008 .

[13]  P. Barach,et al.  Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems , 2000, BMJ : British Medical Journal.

[14]  E. Ackermann The Quality in Australian Health Care Study. , 1996, The Medical journal of Australia.

[15]  L L Leape,et al.  Reducing errors in medicine , 1999, Quality in health care : QHC.

[16]  A. Sheikh,et al.  Reducing error, improving safety , 2000, BMJ : British Medical Journal.

[17]  Richard Horton The uses of error , 1999, The Lancet.

[18]  L. Kohn,et al.  To Err Is Human : Building a Safer Health System , 2007 .

[19]  N. Stanhope,et al.  Reasons for not reporting adverse incidents: an empirical study. , 1999, Journal of evaluation in clinical practice.

[20]  Albert W. Wu,et al.  Medical error: the second victim , 2000, BMJ : British Medical Journal.

[21]  James Reason,et al.  Human Error , 1990 .

[22]  R. Gibberd,et al.  Epidemiology of medical error , 2000, BMJ : British Medical Journal.

[23]  C. Vincent,et al.  Framework for analysing risk and safety in clinical medicine. , 1998, BMJ.