NPSA publishes first NHS patient safety data analysis

More than half a million patients every year suffer as a result of medical errors or incidents while in NHS hospitals. The first public analysis of patient safety data in England and Wales is published by the National Patient Safety Agency (NPSA).

This key report – the first in a series - offers a unique overview of patient safety issues in the NHS for all those working in and using the NHS with an interest in improving patient safety and the quality of care. It features:
• The latest data from the Agency’s National Reporting and Learning System (NRLS) including a breakdown of reports from different healthcare settings
• An analysis of patient safety incidents and emerging issues from the NRLS that are being flagged to the NHS via a new bulletin
• An analysis of reported deaths in the NRLS
• A description of the NPSA’s Patient Safety Observatory (PSO) and how this will support improvement in patient safety
• A comparison of the latest data from the UK with results from six other key studies of adverse incidents from across the developed world
• Case studies to illustrate how the NRLS supports the NPSA to improve patient safety

Chief Medical Officer Sir Liam Donaldson said: “Patient safety is rightly now a key priority for the NHS – and many other health services around the world. We must ensure that when patients are harmed, sources of risk are identified, solutions are implemented and lessons are learned. But we can only do this if we know what is going wrong. This first report and analysis from the NPSA helps us to understand where systems are weak and drive forward improvement.”

There were 85,342 incident reports to the National Reporting and Learning System (NRLS) between November 2003 and March 31 2005 affecting 86,142 patients. The majority of incidents - 68 per cent – resulted in no harm to patients and about one per cent led to severe harm or death.

Reporting levels are increasing rapidly. Almost 75,000 reports were sent to the NRLS in the second quarter of the year between April and June.

230 Trusts reported to the NRLS during the period covered by the PSO report. In a separate analysis within the report, information from 18 of these acute Trusts that have reported incidents consistently over a three month period was used to estimate reported incidents and deaths for the whole of England.

From this analysis we estimate that there would be approximately 572,000 incidents and 840 deaths reported to the NRLS each year from acute hospitals.

Professor Richard Thomson, NPSA’s Director of Epidemiology and Research said: “It must be remembered that the great majority of NHS care is safe and effective with over a million patients successfully treated every day. However, it is inevitable in complex healthcare systems, treating often very sick patients, that sometimes things can and do go wrong.

“When things go wrong it is usually as a result of a problem in the system within which staff work. The NPSA will improve patient safety in large part by improving the systems that support staff in providing the highest quality of care.

“Good information is the first step to understanding what needs to be done. But without action, information is meaningless. We use this information to identify issues and highlight priority areas to develop solutions.

“The NRLS is an immensely rich source of data. However, incident reports on their own cannot tell us all we need to know about patient safety. That is why the NPSA has also set up the Patient Safety Observatory to bring together data from our reporting system with other sources of information such as confidential inquiries, litigation bodies, clinical data, industry, the public and patients. Together, these will provide a more complete picture of patient safety.”

Commenting on the study to estimate reported deaths and incidents in England, Professor Thomson said:“The number of incidents is of the same order of magnitude as previously quoted estimates of 850,000 adverse events a year but the number of deaths is considerably lower than the widely quoted figure of 40,000. Our analysis of reported deaths to the NRLS will contribute to the debate about the size of the problem, but further research is needed to arrive at a more precise figure.

“Nonetheless, every death is a tragedy for the patient, their family and, indeed, for the staff involved. We are committed to working with the NHS to prevent such tragedies.”

A new publication for the NHS is also launched by the NPSA today. Patient Safety Bulletin, a review of learning from patient safety incidents, has been developed to rapidly feed back data and safety concerns to NHS organisations and healthcare professionals.

It aims to raise awareness of specific patient safety problems, share evidence and where possible provide practical advice on how to minimise the risks. It will help to fulfil the NPSA’s commitment to feed back issues and share learning with the tens of thousands of NHS staff who take the time to report incidents and issues to the NPSA. The first issue features a number of emerging themes. They include:
• Safe medication practice with anticoagulant medication. The NRLS data included 311 incidents involving anticoagulants with two deaths. A recent study found that 6.5 per cent of hospital admissions were due to adverse drug events with problems caused by the interaction of anticoagulant medication and some painkillers featuring most commonly. Approximately 500,000 patients take anticoagulant medication at any one time.
• Missing equipment on crash call trolleys is putting critically ill patients at risk. Evidence is emerging from NRLS data of missing or unserviceable equipment on crash call trolleys. Trusts should ensure they have robust systems in place for the replenishment of trolleys.
• The management of patients with a tracheostomy. An issue has emerged over the care of tracheostomy patients, particularly when they are being cared for on general wards following time in the Intensive Care Unit. The NPSA is aware of four deaths in these circumstances. Management of these patients on general wards may be more risky than healthcare staff currently realise though this should be seen in the context of more than 10,000 tracheostomies
carried out in the NHS annually.

NPSA Joint Chief Executive Susan Williams said: “This report reflects the efforts of the tens of thousands of NHS staff who have taken the time and trouble to report errors and system failures to us so that we can identify what needs to change and make healthcare safer for patients.

“It demonstrates that having gained knowledge of issues, action has been taken by the NPSA and the NHS to address these issues. It is further proof that the NHS is at the forefront internationally of tackling patient safety issues head on and the NPSA has an important part to play in this,” she said.

http://www.npsa.nhs.uk/site/media/documents/1261_PSO_RepotNewsRelease.pdf