24

the ADE and whether or not it had been preventable. For each ADE judged to have been preventable, the hospital staff involved in providing the patient with the medication were interviewed by a peer and asked to describe the circumstances surrounding the incident, to describe how the event had occurred, and to self-assess their competency and skills, decision-making style, openness to change, duration in the service or job, the amount and quality of supervision they had received, and the relationship of the incident to the timing of their shift. Consent was not obtained from patients within the unit. Project staff reported that several of the medical staff who had made errors did not want to discuss those errors with interviewers because they were scared about being reprimanded for their mistake. As stated by the project staff member, “We had to reassure them about the confidentiality issues and it worked most of the time.” The project was approved by the REC at each of the two hospitals. During the review process, it was decided that if, during the course of the project, staff identified patterns of care that were harmful to a patient, it was the duty of the project staff to immediately inform the hospital staff and the appropriate authorities so that the recurring error could be corrected, but without retribution to any individual employees. Case study 3 – Assessing the level of risk and minimizing risk 19Interpreting existing guidance The following strategies can help minimize risks in patient safety research: The “no blame” approach to patient safety improvement Patient safety improvement is based on the understanding that most harmful incidents occur not because of negligent or unprofessional behaviour, but, instead, because of systemic problems with the manner in which health care is delivered.