Learning From Medical Errors in Invasive Procedures: Current Situation and Perspectives of Improvement: A...

Learning from medical errors prevents their recurrence. This study examined the management of safety incidents and medical errors, as well as the learning process.

A semi-structured interview was conducted with NHS practitioners involved in invasive procedures. An inductive thematic analysis was followed to create descriptive themes. Analytical themes have been identified based on the descriptive themes.

The interviews included 15 participants (11 consultants, two senior trainees, and two senior theatre nurses). Many are unfamiliar with the definitions and classification of medical errors. Concerns are raised about under-reporting important incidents and over-reporting futile incidents. There was a clear division in reporting near misses. The majority have a pathway for managing medical errors in their organisations. However, the main concern was the lack of feedback. The majority believe M&M meetings provide the best platform to discuss medical errors, though there are concerns about the meetings' length, case selection, and the absence of anonymised discussions. The participants believe central reporting could lead to change, but the lack of horizontal dissemination of lessons learned is a significant defect. Confidentiality, the reputation of trust, fear of public opinion and politicians, and the negative role of the media all hinder the publication of medical errors and the learning of lessons. There is a lack of formal support for the second victim and a prevalence of defensive medicine.

There are concerns related to the process and purpose of incident reporting. M&M meetings are the preferred forum for clinicians to discuss and learn from errors. The main problems are the lack of feedback and the horizontal dissemination of learning lessons. Publishing about medical errors is a sensitive subject influenced by many factors. There is a need for a formal programme across the NHS to support the second victim. Defensive medicine is the new norm.