Another topic raised by Naomi Fulop was how media and political agenda play different roles for Healthcare Associated Infections (HCAI) and medication errors. This may explain why professional tend to accept much higher rates of error for the latter than for the former (Naomi did a study and found that on average 40% of patients in the ward studied had at least one drug omission in the past 24h) – the stronger external pressures lead to a much lower accepted level for errors.
This demonstrates the importance of context, something I also came across several times in my PhD. Naomi also touched on a particular type of context: contra-productive incentives, which lead to errors being hushed up instead of reported (which is the prerequisite for learning). For example, if a “never event” occurs during surgery and is reported the hospital will not be reimbursement for the procedure and faces potential fines. However, she also argued that more research is needed to investigate which contextual factors are related to safety and quality, which of these are modifiable, to which level and what their respective relevance is.
I fully agree.