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National Patient Safety Agency

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

24 March 2010



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


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


Today’s figures show that the number of patient safety incidents reported to the NPSA as having resulted in severe harm or death have decreased from 290 to 238 compared to the same period last year. *


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 22,500 to 27,049 as well as an overall increase from 24,808 to 29,693 for the total number of patient safety incidents between the two periods.


From these, the most commonly reported incident types are patient accident (38 per cent/11,317 incidents), access, admission, transfer, discharge (nine per cent/2,752 incidents) and treatment or procedure (seven per cent/2,185 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 1000 Lives - a national campaign aimed at reducing risks to patient safety by implementing life-saving interventions developed by clinicians in Wales.  Interventions include better management of medicines, reducing healthcare associated infections and surgical complications and improving general medical and surgical care.


The NPSA 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.


NHS Wales Chief Executive, Paul Williams, said:“Improving the safety and quality of healthcare in Wales is the key to ensuring patients receive the best care.  Patient safety is an integral part of our five-year Strategic Framework for the health service in Wales.  We have already achieved so much through the work of the 1000 Lives Campaign, and we have seen unprecedented clinical and staff engagement.  We need staff to champion patient safety and improvement in every ward, every clinic, every community - a revolution that will continue to improve Welsh healthcare. Our patients have a right to expect no less.”


Chief Medical Officer for Wales, Dr Tony Jewell, said:“Every year thousands of patients receive high quality, safe and effective healthcare, but healthcare can be complex and sadly there will be occasions when mistakes can and will still happen. However, as these figures show, it is important to remember that most of those will not result in harm.  I am encouraged to see the further increased levels of reporting. This shows that the NHS in Wales is an open and transparent organisation and is determined to learn from all incidents. We know from research that high reporting is a positive indicator of an open and supportive safety culture.


“These figures published today demonstrate how seriously our staff take patient safety and are prepared to learn from the occasions when things did not go as well as we would all wish. It is only though such shared learning that we will reduce the risk of them happening again.”


Jill Galvani, Director of Nursing, Midwifery and Patient Services at Betsi Cadwaladr University Health Board (BCUHB) said: “From its inception, the BCHUB have believed that ownership of the incident reporting process should be at the grass roots level upwards in that each area within the organisation had access to the Datix incident reporting system and that the use of information for lessons learnt belonged to all.


“The organisation has developed a specific training programme to help staff report incidents. In addition, the organisation has supported this process through resource dedicated to ensure consistent uploading of incidents to the National Reporting and Learning Service. 


“Staff are actively encouraged to report incidents through the use of newsletters, one-to-one support and confidential meetings with risk management and clinical governance personnel.  Incident data has been used at the various meetings held within the organisation from the executive teams to ward and team meetings thereby providing staff with the encouragement that their reporting of incidents has been taken seriously and change has resulted from their efforts.”




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.


Access, admission, transfer, discharge – for example,unexpected re-admission or re-attendance of a patient/delay or failure with a patient’s discharge. 


Treatment, procedure – for example, a delayed procedure.


  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.