England is to set up a new agency to improve safety for NHS patients, with a mandatory system for reporting failures, mistakes, and “near misses.”
The National Patient Safety Agency will act as an independent body within the NHS, with the aim of collecting and analysing information on adverse events from local NHS organisations, NHS staff, patients, and carers. The agency will then feed back any lessons learned into practice, organisations, and delivery. Where risks are identified, the new body will develop solutions designed to prevent harm, set out national goals for risk reduction, and establish mechanisms to track progress towards achieving the goals set.
England's chief medical officer, Professor Liam Donaldson, said: “It is estimated that 850000 incidents and errors occur in the NHS each year. This is unacceptable.” He added: “While it is an inescapable fact of life that people make mistakes, there is much we can do to reduce their impact and so reduce the risk for patients. The new agency will be a catalyst for this.”
He suggested that the agency's system of identifying, recording, and analysing adverse events will provide the basis for shifting to a more “blame free, open NHS,” where lessons will be shared and learnt.
The rationale for the new agency was set out in a report published last week, Building a Safer NHS for Patients. It argued that most health services have previously underestimated the scale of unintended harm or injury experienced by patients as a result of medical error and adverse events in hospitals and other healthcare settings. This is changing, with patient safety, medical error, and adverse event reporting becoming high priorities in healthcare systems around the world.
The report acknowledged that health care is a complex and sometimes high risk activity in which adverse events are inevitable. This is not unique, however, and there are many parallels with other organisations, such as the aviation industry, which was consulted during development of the report's recommendations. The report concluded that capturing and recording information on adverse events and analysing them “in the right way” was an essential step to reducing risk to patients.
The new reporting system will be based on agreed definitions of adverse events and near misses, which, it is hoped, will move gradually to agreed international standards. All staff will be given detailed guidance on these definitions, and there will be a standardised format for reporting. It is hoped to shift to a “no blame” culture that will encourage staff to report adverse events, mistakes, and near misses. There will also be efforts to improve expertise in root cause analysis in order to identify causes and system related factors that result in serious adverse events.
Assistant director of the Patients' Association, Simon Williams, said: “We give a cautious welcome to the National Patient Safety Agency. However, we hope that it will not confuse patients even more about where to turn when things go wrong in the NHS.” He added: “Collecting information on adverse events will only be helpful if it is acted upon. Only time will tell if this happens in practice.”
Building a Safer NHS for Patients can be seen at www.doh.gov.uk/buildsafenhs