1 Awareness of patient safety incidents
1. Every day over one million people are treated
successfully by the National Health Service. Although patient
care is generally of a high standard, the scale and complexity
of patient interventions means that patients can sometimes suffer
unintended harm. Other National Audit Office and Committee of
Public Accounts' Reports have highlighted concerns that the NHS
has limited information on the extent and impact of clinical and
non-clinical incidents; and that trusts need to improve their
understanding of the causes, learn from them, and share good practice
across the NHS more effectively.[2]
2. The system for monitoring and reporting incidents
has, over time, become very complex (Figure 1). By 2000,
there were more than 30 different reporting routes. The Chief
Medical Officer's report, An organisation with a memory (2000),
acknowledged that the NHS was failing to learn from things that
went wrong and had limited systems in place to put things right.
The Department estimated that one in ten patients admitted to
NHS hospitals would be unintentionally harmed, a rate it believed
to be roughly similar to other developed countries. Around 50%
of these incidents could have been avoided if lessons from previous
incidents had been learned.[3]
3. The Chief Medical Officer's report identified
the conditions needed to improve people's confidence in the NHS.
It advocated a change in the safety culture, from one based on
blame, to an open reporting culture to transform the NHS into
an effective learning organisation. Central to this change was
the need for a national reporting system, with a comprehensive
taxonomy for incidents, and robust methods for evaluating trends
in incident rates.[4]
4. The National Audit Office census of acute, mental
health and ambulance trusts in September 2004 (updated in August
2005) was the first co-ordinated attempt to analyse the extent
and impact of the reporting problem and what was being done at
trust level to address the issue. It found that all trusts had
established effective reporting systems, although under-reporting
remained a problem with some staff groups, types of incidents
and near misses.[5]
5. The census revealed that in 2004-05 a total of
974,000 incidents and near misses, including some 2,181 patient
deaths, had been recorded by trusts. Some trusts' incident reporting
systems recorded few incidents and others recorded many thousands
(Figure 2). This data on its own does not provide a clear
indication of how safe a trust is. Those with low levels of incidents
per 1,000 members of staff may be discouraging reporting and vice
versa.
Figure
1: Key organisations in the complex regulatory and support landscape
for patient safety from an NHS trust perspective (pre 2001)
Source: National Audit Office
We also found that there was no correlation between
the numbers of performance "stars" that a trust had
received and the number of incidents reported. The figure on reported
deaths also differs from other published estimates but in reality
the NHS simply does not know.[6]
Figure
2: In 2004-05 similar types of trusts reported widely different
numbers of incidents per 1000 members of staff
Source: National Audit Office
6. Local reporting is dependent on staff willingness
and perception of what, when and how to report. Poorly designed
forms, failure to recognise that an incident needs reporting,
being too busy and a lack of feedback on the outcome of a report
are the main reasons for not reporting. Trusts said that fear
of retribution undermines staff's willingness to report. They
also named concerns about the risk of a claim under the NHS clinical
negligence scheme as reasons cited by staff as having discouraged
them from apologising or from being open following an incident.[7]
7. Few NHS acute trusts routinely told patients when
they had been involved in an incident. For example, only 24% routinely
informed patients when they were involved in an incident and 6%
did not inform patients at all. This lack of transparency and
openness has a detrimental effect on patients' confidence in the
NHS and in their ability to manage their own health. There may
also be implications for their continuing care as patients' general
practitioners (GPs) are also likely to be unaware of the incident.[8]
8. A few trust boards include information on patient
safety incidents in their trust board papers but most trusts do
not publish the numbers of incidents. Consequently, whilst this
information may be considered relevant to patients in exercising
patient choice, GPs do not have such information. Neither do they
have any information on incidents in independent provider organisations.
The only information on safety available to GPs is on trusts MRSA
bacteraemia rates and, from 2006, patients will also be able to
access reports from the Healthcare Commission on achievements
against the Standards for Better Health.[9]
2 C&AG's Report, Executive Summary paras 1-2, 1.1
and Appendix 1 Back
3
ibid, Executive Summary paras 1, 14, 1.1; Qq 4, 23 Back
4
C&AG's Report, paras 1.1, 2.27 Back
5
ibid, Executive Summary paras 5-6 and Appendix 2 Back
6
C&AG's Report, Figures 1, 5, 6, paras 2.10-2.11; Qq 54-57,
127 Back
7
C&AG's Report, Figure 9; Qq 2, 28, 137 Back
8
C&AG's Report, para 1.10; Qq 134, 138-139 Back
9
Qq 35-37 Back
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