Why are mistakes made?

This is a question and a philosophical debate that goes far beyond this paper.  Before we can begin to try and assess how to improve patients’ safety there has to be some analysis about why mistakes are made in the first place and how we can address such mistakes in the future. 

There is no mens rea (literally – “a guilty mind”) in negligence.  It is very, very rare to find healthcare practitioners who abuse their position by way of a criminal act. Beverley Allitt and Harold Shipman did so, but they are the rarity.  The accepted starting point has to be the vast majority of healthcare practitioners have no intention to make any sort of mistake when they go into practice.

That being said, whilst there is no intention to harm, injuries do occur and, for legal purposes, they are judged to happen when practitioners do not achieve the expected standard. The reasons for failing to attain standards will be considered further into this paper, but the starting point is to acknowledge that, despite the lack of intent, liability for harm does arise. 

Various reports have been produced by the NHS and there have been a number of high profile public inquiries (Bristol heart operations, Alder Hey organ retention, Shipman, to name but 3). There have also been confidential enquiries and independent reviews which have considered where mistakes have been made and various suggestions have been put forward to improve patients’ safety. However, it is unclear what information the NHSLA feed back into the system to stop the problems at source rather than reacting to the consequences.

A variety of reasons are put forward as to the causes of adverse incidents:-

• Inappropriate training
• Inappropriate systems
• Pressure of work
• Lack of resources

Attempting to identify the causes of adverse incidents is, of course, essential. However, this analysis needs to be built on and fed back into the system to reduce the chance of the same issues arising again.

> Why are mistakes repeated?