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National Patient Safety Agency

NPSA data show more trusts are reporting patient safety incidents (England)

15 September 2010

Reported instances of death, severe and moderate harm are falling against a backdrop of increased reporting by trusts across England.


Today’s figures show that the total number of patient safety incidents reported to the NPSA was 569,165 between 1 October 2009 – 31 March 2010 – an increase of four per cent (22,577) compared to the previous reporting period (April – September 2009).  The number of trusts that have reported incidents to the NPSA has increased from 99 per cent to 99.7 per cent and the volume of patient safety incidents that have occurred and resulted in severe harm or death has dropped from 3,572 to 3,509 during the same periods. 


Findings also show that awareness of the importance of reporting no or low harm patient safety incidents has also increased.  They show a rise in the number of no and low harm patient safety incidents occurring between 1 October 2009 – 31 March 2010 from 473,162 to 494,540 compared to the previous period.


The most commonly reported categories related to patient accident (30 per cent/159,561 incidents); medication (11 per cent/56,483 incidents); and treatment, procedure (10 per cent/53,572 incidents).


Director of Patient Safety Dr Suzette Woodward said: “Patient safety is a real priority for the NHS.  Trusts across England are reporting more patient safety incidents to us, giving the service an even greater opportunity to learn and to ensure the risk of repeated episodes are minimised as much as possible.”


Dr Woodward added: “These data also give trusts the opportunity to examine closely their own patterns of reporting and look at how they compare against other similar organisations.  It will also aid understanding of their performance and help identify patient safety areas that require local action planning to reduce harm to patients.”


For a full breakdown of figures, http://www.nrls.npsa.nhs.uk/patient-safety-data/organisation-patient-safety-incident-reports/


Notes to editors
The 389 organisations from England reported a total of 569,165 patient safety incidents to the NRLS between 1 October 2009 and 31 March 2010. The corresponding figure for the previous period (1 April 2009 and 30 September 2009) was 546,588.
The number of incidents that occurred between 1 October 2009 and 31 March 2010 and were submitted to the NRLS by 18 June 2010 was 527,954 which is a four per cent increase on the previous reporting period. These are the incidents we use to base the analyses of reporting rate, incident type and degree of harm in the public reports.

Over recent months, the NPSA has issued guidance on:

• intravenous fluids for neonates;
• the importance of checking patients’ weight before treating clots;
• pressure ulcers;
• insulin safety guidance issued to reduce wrong dosages.


* 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

2. Following the publication of the Arms Length Body Review on 26 July 2010, the NPSA has stressed the importance for all NHS organisations across England and Wales to continue reporting patient safety incidents through the National Reporting and Learning System. This is so that trends in safety incidents can be identified and acted upon as early as possible.  This aspect of our work will continue within the new proposed structure of the NHS Commissioning Board and we will continue to work together in partnership with NHS organisations to make services even safer for patients.  We will continue to monitor the implementation of all patient safety alerts and guidance.