METHODOLOGY AREAS: Accident and incident investigation and modelling

Medical device error and failure reporting: Learning from the car industry

Journal of Patient Safety and Risk Management ◽

10.1177/25160435211008273 ◽

2021 ◽

pp. 251604352110082

Author(s):

Arkeliana Tase ◽

Peter Buckle ◽

Melody Z Ni ◽

George B Hanna

Keyword(s):

Reporting System ◽

Current System ◽

Learning System ◽

Healthcare Sector ◽

Patient Harm ◽

Car Industry ◽

Root Cause ◽

Incident Investigation ◽

Initiating Factors ◽

Failure Reporting

Background Improving the design of technology relies in part, on the reporting of performance failures in existing devices. Healthcare has low levels of formal reporting of performance and failure of medical equipment. This paper examines methods of reporting in the car industry and healthcare and aims to understand differences and identify opportunities for improvement within healthcare. Methods A literature search was carried out in Pubmed, Medline, Embase, Engineering Village, Scopus. NHS England and MHRA publications and guidelines were also reviewed. Focus was placed on the current system of reporting in both industries, known degree of patient harm, initiating factors, barriers, quality and methods of incident investigation and their validity. The findings were used to compare error reporting system in the two industries. Results Derivation of healthcare incident data from different sources means the full extent of patient harm is not known. For example, in 2012 there were 13,549 and 38,395 incidents reported by MHRA and NRLS (National Reporting and Learning System) respectively leading to uncertainties on the extent of the problem. The car industry emphasises the role of reporting source in ensuring data quality. Utilising some aspects of this approach might benefit healthcare reporting. These include a specific reporting system that stresses the importance of organisational learning in improving safety and recognises the limitations of root cause analysis. Conclusions Learning from reporting systems within the car industry may help the healthcare sector improve its own reporting, aiding healthcare performance.

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