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National Patient Safety Agency

NHS places reporting and learning from patient safety incidents at top of its agenda - England

24 March 2010


The number of reported patient safety incidents that resulted in death has fallen, against a backdrop of increased awareness, learning and reporting by NHS organisations across England.


That is according to the National Patient Safety Agency (NPSA) which has today published Organisational Patient Safety Incident reports for each trust.  They summarise incidents reported by frontline NHS staff that occurred between 1 April and 30 September 2009. 


Today’s figures show that, month on month, the number of trusts that have submitted regular reporting has increased.


They also show the number of patient safety incidents reported to the NPSA as having resulted in death has decreased from 1,856 to 1,160 compared to the same period last year. *


In addition, the number of reported cases that resulted in severe harm to the patient fell from 3,643 to 2,412. 


Awareness of the importance of reporting no or low harm patient safety incidents has also increased.  Today’s figures show a sharp jump in the number of reports received by the NPSA from 379,345 to 473,162 between the two periods.


From these, the most commonly reported incident type is patient accident (31 per cent/154,538 incidents); treatment, procedure (10 per cent/51,393 incidents); and medication (10 per cent/50,950 incidents). **


The NPSA’s Director of Patient Safety, Dr Suzette Woodward, explained:

“These latest data provide real evidence of an improved patient safety culture in the NHS with a decrease in the severity of incidents reported and a corresponding, real increase in the number of patient safety incidents reported to the NPSA across all categories.  This trend is extremely positive and goes to show just how seriously frontline services view reporting and, more importantly, learning from incidents.


“The NPSA is at the forefront of supporting the NHS to improve the safety of patient care, as they balance the delivery of high quality services while improving productivity and reducing costs.  Our advice and recommendations help organisations prioritise their activity within this complex agenda.


“Strong leadership from boards will help frontline services to be even safer for patients.  These organisational feedback reports will allow boards to look at their own patient safety strategy within their organisation.”


The NPSA works closely with NHS staff, including doctors, nurses, pharmacists and safety improvement experts to analyse the incident reports and identify common safety problems which need action across the NHS.  


Over recent months, the NPSA has continued to support Patient Safety First – a national campaign aimed at reducing harm to patients by changing practice in specific clinical areas, based on existing evidence.


It has also produced guidance on gentamicin, vaccine storage, monitoring of patients prescribed lithium, safer spinal and epidural devices and ‘Being Open’ – a framework for improving communication with patients and their families when things go wrong.


Professor Sir Bruce Keogh, NHS Medical Director said:  "Patient safety is our top priority and the vast majority of NHS patients experience good quality, safe and effective care.We have worked hard to focus the NHS on the importance of reporting and learning from patient safety incidents, and these figures show that this is having an impact.  The figures show an increase in the total number of reported incidents, but a drop in the number of serious incidents, which is encouraging.

"It is only through reporting on this scale that we can analyse otherwise rare events, and work out how to prevent them so they are not repeated elsewhere in the NHS.

“From 1 April, all NHS Trusts will be required to meet a broader set of minimum standards to register with the CQC - a legal requirement for them to operate. This will include a requirement for all NHS organisations to report all serious incidents."


Cynthia Bower, Chief Executive of the Care Quality Commission, said: "I strongly welcome the increase in reporting and urge trusts to improve levels of reporting further still.  These figures are vital to help trusts understand the types of patient safety incidents that they need to focus on and manage in order to improve patient safety.  This will be particularly important from 1 April, when, under the new registration system, reporting specific incidents to the NPSA will become mandatory.  Trusts that don't report incidents could face enforcement action.  Trusts that report incidents show that they are monitoring safety as an important aspect of their operational work and that they are contributing to common learning across all trusts.”


According to today’s data, Leeds Teaching Hospitals Trust is one of the most committed NHS organisations to learn from patient safety incidents across England.  The trust is also one of the highest implementers of the NPSA’s patient safety alerts.


Director of Quality, Craig Brigg, said: “The publication of organisational level data by the NPSA is important for the trust.  This enables us to compare our incident reporting profile with other organisations and to consider where improvements need to be made. 


“When implementing alerts from the NPSA, we nominate lead individuals whose task is to ensure any recommendations and actions are implemented. A recent example of this concerned the implementation of the WHO Surgical Safety Checklist which has led to increased team working between surgical, theatre and anaesthetic teams.  This has led to significant improvements in services and has meant teams have developed a clear understanding of each other’s roles during surgery.”




Notes to editors


* Definitions of levels of harm:


No harm:  Impact prevented – any patient safety incident that had the potential to cause harm but was prevented, resulting in no harm to people receiving NHS-funded care.


Impact not prevented – any patient safety incident that ran to completion but no harm occurred to people receiving NHS-funded care.


Low: Any patient safety incident that required extra observation or minor treatmentand caused minimal harm, to one or more persons receiving NHS-funded care.


Moderate: Any patient safety incident that resulted in a moderate increase in treatmentand which caused significant but not permanent harm, to one or more persons receiving NHS-funded care.


Severe: Any patient safety incident that appears to have resulted in permanent harmto one or more persons receiving NHS-funded care.


Death: Any patient safety incident that directly resulted in the deathof one or more persons receiving NHS-funded care.



** Examples of the most commonly reported incident types


Patient accident – for example patient slips, trips and falls.


Treatment, procedure – for example, a delayed procedure.


Medication – for example, wrong dose, incorrect frequency or wrong drug given to a patient.



  1. Media enquiries to the NPSA Press Office:

Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk

Dominic Stevenson – 020 7927 9351 / dominic.stevenson@npsa.nhs.uk

Out of hours – 0788 411 5956


  1. The National Patient Safety Agency (NPSA) is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.npsa.nhs.uk.