Select Committee on Public Accounts Fifty-First Report


Every day the NHS treats over one million people successfully. Healthcare does however rely on a range of complex interactions of people, skills, technologies and drugs. Sometimes surgical treatments go wrong, medication errors occur and patients can fall or have other accidents.

The drive to improve patient safety started in 2000 with the Chief Medical Officer's report An organisation with a memory. This found that a blame culture and the lack of a national system for sharing lessons learnt were key barriers to identifying and then reducing the number of patient safety incidents. The Report estimated that one in ten patients admitted to NHS hospitals are unintentionally harmed, costing the NHS around £2 billion a year in extra bed days and some £400 million in settled clinical negligence claims. Around 50% of incidents could be avoided if lessons from previous incidents had been learnt. These findings were similar to those of other developed countries.

In response, the Department of Health (the Department) published Building a safer NHS for patients, which set out the Government's plans, timetable and targets to promote patient safety, including establishing the National Patient Safety Agency. The Agency's objectives were to develop a mandatory national reporting scheme by December 2001 for incidents and near misses, assimilate other safety-related information from a variety of existing systems, learn lessons and develop solutions. At the time trusts had to report to one or more of over 30 different organisations depending on the type of incident. There was an expectation therefore that the creation of the Agency would reduce the complex regulatory framework for monitoring quality and safety.

On the basis of a Report by the Comptroller and Auditor General,[1] the Committee took evidence from the Department of Health, the National Patient Safety Agency and the Chief Medical Officer for England.

The Committee found that in 2004-05 some 974,000 patient safety incidents and near misses were recorded on NHS trusts' reporting systems. NHS trusts need to bring down the level of avoidable incidents, particularly those leading to serious harm and death, through rigorous implementation of safety alerts and adoption of high impact, evidence based solutions such as those promulgated by the National Patient Safety Agency and the Institute of Innovation and Improvement.

There have been some notable improvements at NHS trust level in developing a more open and fair reporting culture, reflected in the year on year increase in the numbers of reported incidents and near misses. Nevertheless, under-reporting remains a problem (trusts estimate that on average 22% of incidents go unreported, mainly medication errors and incidents leading to serious harm) and similar types of trusts report widely different levels of incidents per 1,000 members of staff. Few trusts have formally evaluated their safety culture. Furthermore, trusts have not done enough to inform patients when things go wrong or to involve patients in developing solutions to incidents.

Insufficient progress has been made in achieving the Department's plans in Building a Safer NHS for Patients and there is a question mark over the value for money being achieved by the National Patient Safety Agency, evidenced in the main by the delays and cost over-runs in establishing its National Reporting and Learning System and in the limited feedback of solutions to reduce serious incident that has, so far, been provided to trusts. The National Patient Safety Agency has also failed to evaluate and promulgate solutions that have been developed at trust level.

1   C&AG's Report, A safer place for patients: learning to improve patient safety (HC 456, Session 2005-06) Back

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