They interviewed 40 healthcare professionals about the standard error reporting system and assessed nearly 1,000 drug error reports. Interviewees described the system as a ‘thankless treadmill’ and said there was sometimes a focus on individuals ‘culminating in blame without obvious justification’.
The researchers piloted a new scheme with a less formal approach in one trust for three months. Reporting rates at the trust were maintained and increased in some units after the new system was introduced.
Author Gerry Armitage, senior research fellow at Bradford Institute of Health Research, wrote: ‘Reporting schemes can increase learning and decrease inherited blame if carefully structured and managed.’