NHS aims to improve patient safety

Lessons will be learnt from medical mistakes

All medical mistakes will have to be officially reported, whether or not the patient has been harmed, in a bid to improve safety in the NHS.

An independent body is to be set up to log failures, mistakes and errors which occur in hospitals and GP surgeries.

The National Patient Safety Agency (NPSA) will run a mandatory reporting system for incidents and "near-misses".

If something has prevented the patient being harmed but a problem has been revealed, it will still have to be reported under the new system.

We want the experience of a patient in one part of the country to benefit a future patient in another part of the country

Professor Liam Donaldson,
Chief Medical Officer

Patients will also be able to report incidents.

Practices used in other areas such as the airline industry could also be adopted, said Chief Medical Officer (CMO) Professor Liam Donaldson, launching the agency.

As in the aviation industry, bulletins could be issued containing details of adverse events that have happened and how to avoid them in the future.

The NHS could even see an equivalent of airline safety procedures, said Professor Donaldson, who outlined the possibility of briefings to teams who are about to carry out high-risk procedures such as complex heart surgery or chemotherapy treatments.

Lessons for NHS

A report published last June estimated 840,000 incidents and errors occur in the NHS every year.

Professor Donaldson said: "While it is an inescapable fact that people make mistakes, there is much we can do to reduce their impact and so reduce risks for patients. The new agency will be the catalyst for this."

Professor Liam Donaldson: 'NHS will be safer'

The CMO told the BBC the aim was for lessons to be learnt from every mistake, and for them to be implemented across the NHS.

"We want the experience of a patient in one part of the country to benefit a future patient in another part of the country."

The "early warning system" was originally promised by the government last year.

The latest announcement promises the agency will be in place by July 2001, but it will spend its first few months issuing guidelines to hospital trusts and GPs on how to categorise incidents and how to report them.

It is anticipated that all NHS trusts and a "significant proportion" of primary care will be joined up to a national system by the end of 2002.

The Committee on Safety of Medicines has also announced it is to look at the problem of medication errors which arise from mix-ups over the packaging or labelling of medicines.

Targets set

There are four specific areas that the NPSA is to address:

• Reduce to zero the number of people dying or being paralysed by maladministered spinal injections by the end of 2001,
• Reducing the number of incidents connected with obstetrics and gynaecology which result in litigation by 25% by 2005,
• Reduce the number of errors connected to prescribed drugs by 40% by 2005,
• Cut the number of suicides by mental health patients who hang themselves from a non-collapsible bed or shower curtain rail on wards to zero by 2002

There have been at least 14 incidents where the drug vincristine was injected into the spine instead of the vein since 1975.

A separate report is being compiled on how that mistake can be avoided.

And 50% of the annual NHS litigation bill relates to claims arising from brain-damaged babies.

It is hoped the cost of the agency and its recommendations will be offset by the money saved in litigation and other costs associated with medical errors.

In February 18-year-old Wayne Jowett died after vincristine was injected into his spine instead of a vein.

In January, three-year-old Najiyah Hussain died after a hospital mix-up in which she was given nitrous oxide, laughing gas, instead of oxygen.

Dr Peter Hawker, chairman of the British Medical Association's consultants' committee, said implementing the strategy would require a "huge change" in the working culture of the NHS, and called for clinicians to be able to report incidents confidentially.

"We have to recognise that a certain level of human error is inevitable and design it out of the process where we can, but currently we work in a blame culture where an adverse incident is often assumed to be the personal fault of an individual."