The first and most important step is to develop an awareness
of the ubiquity of medical error and the potential capacity to
inflict severe harm or death on patients. Reason uses the
term ‘feral vigilance’19 to describe the ever present watchfulness
and alertness required to prevent errors, whether slips,
lapses, or mistakes.
Secondly, consultant anaesthetists have great capacity to
influence what goes on in the operating theatres in which
they work. A safety climate with psychological safety is
more likely to take place when those in a position of responsibility
and leadership make explicit what they are doing and
lead by example. The actions of individuals in turn influence
the climate of an anaesthetic department.
Thirdly, by reporting errors and by encouraging the local
feedback of the analysis of such errors or near misses, the
more likely other members of the team are to do so. Evidence
has shown that as more incidents are reported, the
number of serious adverse events decreases.32
Furthermore, the act of reporting can help the reporter
reflect upon the nature of the error and the factors that
may have contributed.
We should not underestimate our power to influence such
processes by our actions as individuals.