3 What more needs to be done?|
18. The Committee considered it unsatisfactory that
one in ten patients admitted to hospital is unintentionally harmed.
The Department agreed that based on experiences in other high
risk industries such as aviation, year on year improvements (to
1 in 15 or 1 in 20) could in time be achieved. However, like these
other industries it could take the NHS a decade or more systematically
to improve safety to such a standard. More immediate improvements
should be achievable through the advent of the electronic patient
record which is expected to reduce the number of incidents due
to lost, poor or fragmented clinical information and improve drug
dispensing, by eliminating the risk of misinterpretation of clinicians'
19. England is one of the few countries to have a
nationwide approach to patient safety. It has national structures
in place such as: a comprehensive quality framework; national
inspectorates; bodies to help embed an open and fair culture;
systems for reporting and learning; and national training curricula.
This approach should help to identify risks that might otherwise
have been missed and enable solutions to be developed in a systematic,
cost-effective way that avoids duplication. However, the National
Patient Safety Agency has been slow to develop and disseminate
solutions to NHS trusts. Given that enhancements to patient safety
can only happen at trust level, at the interface between healthcare
workers and patients, any national solutions need to be seen by
trusts to be effective.
20. Some trusts still have some way to go to establish
an open and fair culture, including developing more effective
team working and better communication with patients. Trusts also
need to improve routine feedback of data and findings on incidents
to staff, with time for reflection and learning. In those trusts
where these principles are well-established, there are good examples
of local learning to improve patient safety, some of which have
been demonstrated to be cost-effective. The National Patient Safety
Agency has not sought to capture these local examples and doubts
amongst healthcare workers remain as to whether the Agency can
make a difference.
21. The National Reporting and Learning System now
receives 60,000 reports a month, proportionately greater than
any other system in the world, significantly increasing the level
of information the NHS has on the number and extent of patient
safety incidents. The National Patient Safety Agency has yet to
demonstrate that it is using this information and knowledge effectively
to change healthcare practices rather than simply collecting statistics.
22. The Department concurred that, although the National
Patient Safety Agency had produced a number of specific solutions,
the learning system was not yet working as well as it could. Trusts
generally perceive that the Agency has failed to maximise learning
because it has not provided feedback quickly and regularly. The
agreement of the Department to publish quarterly reports from
the Patient Safety Observatory (an arm of the Agency which quantifies,
characterises and prioritises patient safety issues) will go some
way to address this, particularly once information from the reporting
system is brought together with information from other systems
recording complaints and litigation.
23. The Agency will have to analyse nearly one million
incident reports a year, two-thirds of which may not have caused
any actual harm to the patient. The collection of risk based,
aggregate data, would allow the Agency to prioritise more effectively,
for example by gathering details on the number of deaths and serious
injury resulting from patient safety incidents. This would also
enable the Agency to focus on high impact solutions, such as new
methods for dispensing medication to reduce medication errors
(25% of all reported incidents). 
24. The National Reporting and Learning System has
increased rather than reduced the complexity of NHS reporting,
and trusts still have to report the same incidents to more than
one organisation (for example, medical devices errors are also
reported to the Medicines and Healthcare Products Regulatory Agency).
There is a need for greater co-ordination between NHS organisations.
The Department's National Programme for Information Technology
in the NHS is intended to create a single portal for reporting
with data then passed onto the relevant stakeholder.
25. Learning lessons is most likely to come from
the information on contributory factors and currently only a small
percentage of reports to the National Patient Safety Agency contain
this information in either the data or free text fields. The National
Patient Safety Agency would like to see more trusts providing
this information. It was working with NHS Connecting for Health
to explore making contributory factors a mandatory field in the
national specification for risk management systems.
26. Independent providers of NHS funded care are
covered by the Healthcare Commission's inspection process, which
requires them to comply with National Minimum Standards, including
having an incident reporting system. Currently, however, independent
providers are not obliged to share that data with any NHS body.
Service Level Agreements should ensure that such data on patient
safety incidents is made public. Indeed, if GPs and their patients
are to be able to make informed choices between providers, as
part of the new patient choice agenda, there will be a need for
robust comparable data on all providers.
27. For this reporting and learning to have a demonstrable
impact on the experience of patients, the level of data submission
and implementation of safety alerts and guidance at trust level
needs to be monitored. Trusts self-certify that they have implemented
safety solutions from the Safety Alert Broadcast System (a Departmental
system for notifying trusts of matters that require attention)
and strategic health authorities monitor this data. However, actual
compliance with this guidance is not audited.
28. Worldwide there are few examples of where reductions
in risk can be quantified and attributed to particular interventions.
Few trusts have quantified the cost of specific patient safety
incidents and the National Patient Safety Agency has only produced
one template business case for trusts to customise to argue for
investment in safety solutions. More information on the cost-effectiveness
of solutions would enable trusts to prioritise scarce resources
29. The NHS needs to be open in its dealings with
patients involved in safety incidents. Patients expect an apology,
a full explanation, to be involved in an investigation, and to
help determine what actions might prevent future harm. Australia
and the Veterans' Health Service of the United States of America
have had policies advocating these principles for a number of
years, and the National Patient Safety Agency's guidance Being
Open, issued in September 2005, has drawn on their experiences.
The Agency has also launched teaching materials to allow trusts
to develop appropriate local policies and give clinicians practice
in informing patients about incidents. The Chief Medical Officer
has produced a report on reforms to the medical litigation system,
Making Amends, and there is a proposed new Bill on this.
30. The Department, through its former agency, the
National Clinical Assessment Authority, has made some progress
in providing support to poorly performing doctors and in resolving
long running suspensions, whilst ensuring patients are protected.
The expanded role of the National Patient Safety Agency now covers
these responsibilities, but is still only providing support to
doctors and dentists. A similar service should be available to
nursing and other clinical staff. Whilst the Chief Nursing Officer
and the National Patient Safety Agency have sought to strengthen
local systems which deal with poor performance of this much larger
group of staff, all staff need equal access to some degree of
18 Qq 22, 24-27, 95-97 Back
Qq 3, 77, 90-91, 116 Back
C&AG's Report, Executive Summary para 6, paras 3.10-3.11 and
Case Examples 6-7; Q 119 Back
Qq 2-3, 7 Back
Qq 26, 86 Back
Qq 117, 133 Back
Qq 19, 112-114 Back
Qq 32-33, 66-69, 87 Back
Qq 35, 38-41, 43-46, 50-53 Back
C&AG's Report, paras 3.25-3.28; Q 98 Back
Qq 89, 94 Back
Qq 29-30, 61, 139 Back