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
- 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.
- 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.
- 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