Keep an eye out for trouble

摘要

SummaryIn May 2008, the National Patient Safety Agency launched a Foresight Training Resource Pack to help nurses develop the 'mental preparedness' they need to identify, respond to, and recover from potential patient safety incidents. Although experienced nurses already use 'error awareness', there has been no formal approach to this kind of training in the NHS. This article describes a strategy for developing foresight skills and explains how the training resource pack works.EVERY DAY more than one million people are treated safely and successfully in the NHS. But the evidence tells us that, in complex healthcare systems, things will and do go wrong, no matter how dedicated and professional the staff.When things go wrong, patients are at risk of harm from patient safety incidents, as defined by the National Patient Safety Agency (NPSA) (Box 1).Between October 1 2007 and September 30 2008, for example, 846,910 patient safety incidents were reported to the NPSA's (2008) reporting and learning system. Sixty six per cent of these incidents were classified as having caused 'no harm' to the patients concerned.Such incidents may include what are often called 'near misses', in which there was potential for harm, or where harm was identified but averted by healthcare staff.Because nurses are at the front line of health care, they are more able that many other healthcare staff to avert such incidents.