SP5.05 Learning From Medical Errors in Invasive Procedures: Current Situation and Perspectives of Improvement: A Semi-Structured Interview

Background Learning from medical errors helps prevent their recurrence. Learning takes formal and informal forms. This study explored the management of safety incidents and medical errors, as well as the learning process involved. Methods A semi-structured interview with NHS practitioners involved in invasive procedures was conducted, featuring 14 questions. An inductive thematic analysis identified descriptive and analytical themes. Results The interviews involved 15 participants (11 consultants, 2 senior trainees, and 2 senior nurses) and lasted 445 minutes. Many were unfamiliar with textbook definitions and the WHO classification of medical errors. Concerns include under-reporting key incidents and over-reporting futile ones, with little learning. Near-miss reporting is divided. Most organizations have error management pathways, but the main issue is lack of feedback. Most believe M&M meetings offer the best platform for discussing medical errors, though concerns exist about meeting length, case selection, and the lack of anonymised discussions. While central reporting could drive change, the absence of widespread lesson-sharing is a major issue. Confidentiality, fear of public backlash, and media influence prevent the publication of errors and lessons. There is also a lack of formal support for second victims and a tendency toward defensive medicine. Conclusions Concerns focus on incident reporting processes and purpose. M&M meetings are preferred for clinicians to discuss errors. Main issues include lack of feedback and horizontal knowledge sharing. Publishing medical errors is sensitive, influenced by multiple factors. A formal NHS program is needed to support the second victim. Defensive medicine has become the norm.