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Reporting of adverse incidents should be embedded in NHS culture

Methods of reporting adverse incidents and learning from mistakes need to be embedded in NHS systems and culture, according to a report by the independent healthcare watchdog for England and Wales: “State of healthcare 2008” published last week (10 December 2008).

In future all NHS trust boards should routinely receive data on medication errors, infection rates and whether their organisations are delivering safe patient care, the Healthcare Commission has recommended. “Everyone needs to recognise that improved safety is the first step towards a better health service,” the report says.

The Commission said that although patient safety has a higher profile today than in previous years, it is worried about the ability of NHS providers to collect “good” information on safety of care and to use those data to protect patients.

Stronger leadership in patient safety issues across trusts from wards to boards is needed as well as better reporting of incidents and the ability to learn from mistakes, including the introduction of better practices, the Commission said in its fifth annual report to Parliament on the state of the NHS in England and Wales.

The figures fail to reflect the true picture because there is wide discrepancy in the number of trusts that routinely record adverse incidents, the report says. Between April and June this year 7 per cent of acute trusts, 14 per cent of mental health trusts and 13 per cent of primary care trusts did not report a single adverse incident.

And although the majority of the Commission’s reviews on errors focus on general practice, just 0.3 per cent of reports during 2007/08 came from that sector, it said.

     Some findings from the Healthcare Commission report

    • Just 49 per cent of all NHS trusts met the Government’s core standards on patient safety in 2007/08 — 2 per cent down on the previous year
    • Research estimates that up to 600 medical errors, mainly linked to diagnosis and treatment, take place in primary care every day
    • The cost of clinical negligence to the NHS in 2006/07 was £579m
    • The number of adverse incidents reported to the National Patient Safety Agency between April 2007 and March 2008 was just under one million, most leading to low-level harm
    • Over 7,500 incidents resulted in “severe” harm and another 3,471 ended in a patient’s death
    • The main cause of reported incidents was patient accidents, with 34 per cent (294,500 cases) associated with some kind of fall; 10 per cent (82,000 cases) were related to treatment and procedures and 9 per cent (76,800 cases) were due to medication errors



    Citation: The Pharmaceutical Journal URI: 10043873

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