Select Committee on Public Accounts Fifty-First Report

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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Prepared 5 July 2006