A case of mistaken identity

An Organisation with a Memory [Department of Health (2000)] indicates that there is a lot of repetition in failure within the healthcare delivery in the U.K. with detrimental effect to those involved. Can lessons be learnt and the cycle of repetition be broken (ibid) by the use of Reason's Br Med J (2000) 768 system approach? This paper presents an example of a Radiographic incident, which demonstrates this approach and explores some of the issues behind it. Factors related to policies and protocols are discussed, as well as the ways in which health care organisational culture can affect the comprehensiveness of incident investigation and the learning potential that can result from an incident review. Suggested ways of adopting the approach are given, especially in relation to the work environment, focusing on how the environment can affect adverse incidents. In conclusion the full-scale implementation of the system approach is suggested as the way to maximise the learning potential from incidents and reduce the cycle of incident repetition