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National critical incident reporting: improving patient safety
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Learning without thought is labour lost; thought without learning is perilousConfucius 551–479 BC
One of the key features of the patient safety ‘movement’ is the belief that safety can be improved by learning from incidents and near misses, rather than pretending they have not happened.1 Critical incident investigation was first used in the 1940s as a technique to improve safety and performance among military pilots.2 This focus on critical indents enabled the researchers to investigate the differences between behaviours that led to success and those that led to failure, and to derive conclusions about how people should be encouraged to act, especially by redesigning their work environments to produce more desirable outcomes. In 1978, Cooper and colleagues3 used what they described as a ‘modified critical incident technique’ to interview anaesthetists and obtain descriptions of preventable incidents. It is now commonplace for individual departments of anaesthesia to record and discuss
1 Lancaster, UK
2 Nottingham, UK
* E-mail: bja@nottingham.ac.uk