Clinical risk management
Changes in perspective
Over the past decade, there have been a
number of events that have had a significant
impact on the NHS and help to explain why
various changes are now taking place and
why risk management within the NHS has
become such a high priority.
These include:
Crown immunity for hospitals
This was lost in 1990 and replaced with
Crown indemnity, to replace clinical
negligence cover by medical defence
organisations. Incredibly, until this time
hospitals were immune from prosecution
over accidents that occurred on the
premises.
Health and Safety Executive (HSE)
In a landmark case in 1996, Norfolk Health
Care Trust was fined by the HSE for breaches
of health and safety law. This was because
the hospital had failed to prevent a patient,
undergoing a routine cardiac angiography,
from accidentally being injected with air
instead of radioactive plaque dye. The
patient subsequently died as a direct result
of this medical error. This ruling had major
implications for NHS trusts across the
country as it highlighted the possibility that
prosecutions under health and safety law
could now be brought in relation to clinical
accidents.