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Press Release - A Safer Place for Patients: learning to improve patient safety

 

3 November 2005

 

 

According to a report today by the National Audit Office, around a half of incidents in which NHS hospital patients are unintentionally harmed could have been avoided, if lessons from previous incidents had been learned. Whilst reporting has improved at the local level, at the national level progress on developing a national reporting and learning system has been slower than envisaged in the Department of Health’s 2001 strategy “Building a safer NHS for patients”. Overall, there remains a clear need to improve evaluation and sharing of lessons and solutions by the large number of organisations with a stake in patient safety. There is also a need for a clear system for monitoring that lessons are learned.

Today’s report by head of the NAO Sir John Bourn on progress made by the NHS in improving the patient safety culture concludes that, at the local level, the vast majority of trusts have developed a predominantly open and fair reporting culture, driven largely by the Department’s clinical governance initiative and more effective risk management systems. There are, however, trusts where a blame culture still predominates. There is also scope for trusts to improve their strategies for sharing good practice.

An NAO survey found that, in response to the encouragement to report, there have been year on year increases in the number of patient safety incidents and in 2004-05, there were around 980,000 reported incidents and near misses. Patient safety incidents are estimated to cost the NHS some £2 billion a year in extra bed days.

A retrospective study of patient records in two English hospitals found that just over 10 per cent of patients experienced an ‘adverse event’. Around half of these (5.2 per cent) were judged to have been preventable. Responses to the NAO survey showed that, in 2004-05, trusts recorded some 2,081 deaths as a result of patient safety incidents, but it is widely acknowledged that there is significant under-reporting of deaths and serious incidents. Other estimates of deaths range from 840 to 34,000 but, in reality, the NHS simply does not know.

According to the NAO, trusts are now more likely to be fostering open and questioning communication between staff in teams. Almost all trusts reported that they had made progress in reducing the culture of blame; but surveys of nurses and other non-medical staff highlighted that they perceived that the blame culture continues to exist in the NHS. And there was still more to do to achieve a fully open and fair culture with regard to communicating with patients. In the NAO survey, 69 per cent of trusts had criteria for staff to follow, but only 24 per cent routinely informed patients when those patients had been involved in a reported incident. And six per cent of trusts did not inform patients at all.

All trusts had established effective reporting systems at the local level - although, despite the general increase in reporting, a substantial number of incidents still go unreported (an estimated 22 per cent, mainly medication errors and incidents leading to serious harm). Reporting of near misses is also low, mainly owing to different perceptions of what constitutes a near miss.

The roll-out of the National Patient Safety Agency’s National Reporting and Learning System has taken two years longer than the December 2002 date originally envisaged. The new target date was for all trusts to report to the system by June 2005, but by August 2005 at least 35 trusts had still not reported any data.

Most trusts pointed to specific improvements derived from lessons learnt from their local incident reporting systems, but these lessons are still not widely promulgated, either within or between trusts. And the National Patient Safety Agency has provided only limited feedback to trusts of evidence-based solutions or actions derived from the national reporting system.

The NAO has made a number of recommendations aimed at enhancing and sustaining the development of an effective safety culture; improving the reliability and completeness of reporting; and encouraging learning and the development of effective solutions. For example: trusts need to evaluate their safety cultures and develop systems in which NHS employees need not fear blame or unequal treatment if they report incidents; and patient safety must become a core part of professional clinical training.

The report also recommends that there should be a clearer definition of ‘near-misses’ and encouragement of staff to report them and that the Department should explore the possibility of a single point to which all staff can report, for example, via the National Programme for Information Technology in the NHS.

Patients also need to be engaged by trusts in identifying important patient safety issues and in helping to design solutions. There should be better dissemination of learning between trusts. And the National Patient Safety Agency needs to expedite its evaluation and feedback programme and focus on developing solutions to nationwide problems with the Healthcare Commission taking responsibility for ensuring that appropriate solutions are implemented across the NHS.

Sir John Bourn said today:

“Reducing unintentional harm to patients in NHS hospitals is a central tenet in the management of healthcare quality and risk. Two factors are crucial to this: the establishment of a culture in which incidents can be reported easily, honestly and without fear of blame; and the ability to ensure that lessons learned from these incidents are successfully promulgated to NHS staff both locally and nationally. What today’s report shows is that the Department of Health and the NHS have made some progress in both of these areas – but not enough.
“There needs to be significantly faster progress at the national level in ensuring effective evaluation of numbers, types and causes of incidents. And lessons and solutions must be better evaluated and shared by all organisations with a role in keeping patients safe.”

Notes for Editors

 

  1. A patient safety incident is defined as any unintended or unexpected event that causes death, disability, injury, disease or suffering for one or more patients. The most common incidents reported were: patient injury (due to falls), followed by medication errors, equipment-related incidents, record documentation error and communication failure.
  2. Press notices and reports are available from the date of publication on the NAO website,
    which is at www.nao.org.uk. Hard copies can be obtained from The Stationery Office
    on 0845 702 3474.
  3. The Comptroller and Auditor General, Sir John Bourn, is the head of the National Audit Office which employs some 800 staff. He and the NAO are totally independent of Government. He certifies the accounts of all Government departments and a wide range of other public sector bodies; and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies have used their resources.

Press Notice 56/05

All enquiries to Barry Lester, NAO Press Office:

Tel: 020 7798 7937

Mobile: 07748 181 692