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Friday, 3 August, 2001, 01:48 GMT 02:48 UK
Patient safety watchdog appointed
Professor Rory Shaw - head of the National Patient Safety Agency
Professor Rory Shaw - head of the National Patient Safety Agency
The government have named the man charged with revolutionising patient safety in the NHS.

Professor Rory Shaw is to be the head of the National Patient Safety Agency, which is to cover England and Wales.

The independent body will collate reports of mistakes made in hospitals and so-called "near misses", whether or not patients have been harmed.

It will decide when to issue recommendations across trusts to ensure that particular error does not happen again.

The report into the Bristol heart baby scandal also supported the NPSA's formation.

Professor Shaw, medical director of Hammersmith Hospital's NHS Trust, told the BBC: "The work of the agency must be directed at putting in place mechanisms which actually do save lives, and actually prevent adverse events happening."


The work of the agency must be directed at putting in place mechanisms which actually do save lives

Professor Rory Shaw
He added that he wanted staff in the NHS to feel they could report such incidents in a "blame-free manner".

Professor Shaw's hospital has developed a system where staff can use a cyber-cafe to log on and report incidents and near-misses.

The first task for the agency will be to work out a method of ensuring all NHS organisations collate information in the same way, and can pass it on to the agency.

But when it does start issuing recommendations, it may suggest changes to equipment, training, or medical procedures.

Scotland has said it is in discussions with the Department of Health to extend the agency's remit to the whole of the country.

Professor Shaw said the sorts of things that occurred in trusts which could change varied enormously.

But he said even things which looked minor could be serious: "For example, a mislabelling on a wristband on a patient going to theatre - but that's an important near miss as the patient may have had the wrong operation."

National systems

The government announced the launch of the agency in April, when it said the NPSA would 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 also said it was to look at the problem of medication errors which arise from mix-ups over the packaging or labelling of medicines.

There have been high-profile clinical mistakes made over the last year.

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

And 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.

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National Patient Safety Agency's Prof Rory Shaw
"It's important that professionals and patients keep us informed"
See also:

20 Nov 00 | Health
Parents 'not told of drug errors'
13 Jun 00 | Health
Plan to stop dangerous doctors
01 Feb 01 | Health
Woman died after drug blunder
24 Jan 01 | Health
Inquiry into cancer drug tragedy
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