Year: 2005
Type: book
Abstract: 1 Every day over one million people are treated \nsuccessfully by National Health Service (NHS) acute, \nambulance and mental health trusts. However, healthcare \nrelies on a range of complex interactions of people, \nskills, technologies and drugs, and sometimes things do \ngo wrong. For most countries, patient safety is now the \nkey issue in healthcare quality and risk management. \nThe Department of Health (the Department) estimates \nthat one in ten patients admitted to NHS hospitals will be \nunintentionally harmed, a rate similar to other developed \ncountries. Around 50 per cent of these patient safety \nincidentsa could have been avoided, if only lessons from \nprevious incidents had been learned. \n \n2 \nThere are numerous stakeholders with a role in \nkeeping patients safe in the NHS, many of whom require \ntrusts to report details of patient safety incidents and near \nmisses to them (Figure 2). However, a number of previous \nNational Audit Office reports have highlighted concerns \nthat the NHS has limited information on the extent and \nimpact of clinical and non-clinical incidents and trusts need \nto learn from these incidents and share good practice across \nthe NHS more effectively (Appendix 1). \n \n \n3 In 2000, the Chief Medical Officer’s report An \norganisation with a memory \n1 \n, identified that the key \nbarriers to reducing the number of patient safety incidents \nwere an organisational culture that inhibited reporting and \nthe lack of a cohesive national system for identifying and \nsharing lessons learnt. \n \n \n4 In response, the Department published Building a \nsafer NHS for patients3 detailing plans and a timetable \nfor promoting patient safety. The goal was to encourage \nimprovements in reporting and learning through the \ndevelopment of a new mandatory national reporting \nscheme for patient safety incidents and near misses. Central \nto the plan was establishing the National Patient Safety \nAgency to improve patient safety by reducing the risk of \nharm through error. The National Patient Safety Agency was \nexpected to: collect and analyse information; assimilate \nother safety-related information from a variety of existing \nreporting systems; learn lessons and produce solutions. \n \n \n5 We therefore examined whether the NHS has \nbeen successful in improving the patient safety culture, \nencouraging reporting and learning from patient safety \nincidents. Key parts of our approach were a census of \n267 NHS acute, ambulance and mental health trusts in \nAutumn 2004, followed by a re-survey in August 2005 \nand an omnibus survey of patients (Appendix 2). We also \nreviewed practices in other industries (Appendix 3) and \ninternational healthcare systems (Appendix 4), and the \nNational Patient Safety Agency’s progress in developing its \nNational Reporting and Learning System (Appendix 5) and \nother related activities (Appendix 6). \n \n \n6 An organisation with a memory1 \nwas an important \nmilestone in the NHS’s patient safety agenda and marked \nthe drive to improve reporting and learning. At the \nlocal level the vast majority of trusts have developed a \npredominantly open and fair reporting culture but with \npockets of blame and scope to improve their strategies for \nsharing good practice. Indeed in our re-survey we found \nthat local performance had continued to improve with more \ntrusts reporting having an open and fair reporting culture, \nmore trusts with open reporting systems and improvements \nin perceptions of the levels of under-reporting. At the \nnational level, progress on developing the national reporting \nsystem for learning has been slower than set out in the \nDepartment’s strategy of 2001 \n3 \nand there is a need to \nimprove evaluation and sharing of lessons and solutions by \nall organisations with a stake in patient safety. There is also \nno clear system for monitoring that lessons are learned at the \nlocal level. Specifically: \n \na The safety culture within trusts is improving, driven \nlargely by the Department’s clinical governance \ninitiative \n4 \nand the development of more effective risk \nmanagement systems in response to incentives under \ninitiatives such as the NHS Litigation Authority’s \nClinical Negligence Scheme for Trusts (Appendix 7). \nHowever, trusts are still predominantly reactive in \ntheir response to patient safety issues and parts of \nsome organisations still operate a blame culture. \n \nb All trusts have established effective reporting systems \nat the local level, although under-reporting remains \na problem within some groups of staff, types of \nincidents and near misses. The National Patient Safety \nAgency did not develop and roll out the National \nReporting and Learning System by December 2002 \nas originally envisaged. All trusts were linked to the \nsystem by 31 December 2004. By August 2005, at \nleast 35 trusts still had not submitted any data to the \nNational Reporting and Learning System. \n \nc Most trusts pointed to specific improvements \nderived from lessons learnt from their local incident \nreporting systems, but these are still not widely \npromulgated, either within or between trusts. \nThe National Patient Safety Agency has provided \nonly limited feedback to trusts of evidence-based \nsolutions or actions derived from the national \nreporting system. It published its first feedback report \nfrom the Patient Safety Observatory in July 2005.
Authors: Amanda Terry, Caroline Mottram, Jonathan A. Round, E. Firman, J. Step, Joe Bourne
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W192462963