We need something much greater than an incident reporting system.
Clinical error is the third biggest killer in hospitals.
Healthcare is a risky business. Simply being in an acute care hospital in Florida carries, on average, a 2000 fold greater risk of dying from the acute care process than air travel. (Dr Paul Barach)
We need a solution feedback loop driven by teams of human factors experts:
Frontline staff need to be able to easily and succinctly inform human factors teams of the hazards in our workplace and what we as front line staff believe are the best solutions to these problems. The human factors experts then review the sustainability, workability, and effectiveness of these solutions. They may propose other solutions that are more suitable. Solutions should then be trialled and driven into place.
Solutions can be implemented at a local level and where necessary communicated between different groups (pods) of human factors experts and implemented internationally.
Perhaps this would have led to the recall of the Draeger Primus APL valve that we are still waiting for.