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National Patient Safety Agency

NPSA response to Healthcare Commission report "State of Healthcare 2008"

Thursday 11 December 2008


In response to the Healthcare Commission’s report on the state of healthcare in England, Dr Kevin Cleary, Medical Director of the National Patient Safety Agency (NPSA), said: 


“The NPSA welcomes the emphasis on primary care reporting and the need to improve knowledge of patient safety incidents in a primary care setting. The complexity of primary care services means that different models of reporting are needed from those used in acute hospitals. The NPSA in partnership with the Royal College of General Practitioners has developed a pilot project for a new system of reporting that is tailored to the specific needs of primary care. Testing of this new system is underway and we are confident that it will yield new insights into the processes of healthcare provision that will ensure safer primary care can be provided. Our experience shows that engaging clinical staff is a key requirement to improving safety in healthcare."


He continued: “The NPSA is committed to improving the quality of the reporting and response to serious incidents.  Frontline NHS organisations can only learn from incidents if they utilise the correct methods of analysis of incidents and share these with the wider NHS through the NPSA. In order to achieve this goal the NPSA is building on its Reporting and Learning System so that the lessons from serious incidents can be utilised by all healthcare organisations in England and Wales. We clinically review all 1500 serious incidents reported to the Agency each month and are using this as a platform to further improve reporting and learning by clinical staff.  Our Rapid Response Reports on risks which need urgent attention are an example of how this development work is already providing timely and actionable solutions for healthcare providers.”




Notes to editors:


Media enquiries to the NPSA Press Office:


View the Healthcare Commission's report "State of Healthcare 2008" (published in December 2008).


The NPSA has developed the General Practice and out of hours reporting (eForm) pilot in partnership with the Royal College of General Practitioners, to help report patient safety incidents in primary care. This will allow the NPSA to identify potentially serious patient safety risks and issues quickly and issue warnings and preventative guidance to other health care providers, if necessary. The NPSA also hopes be able to observe trends, share lessons learned and share ‘good practice’.


Rapid Response Reports are page-long notices which are based on evidence of harm to patients and identify clear actions for healthcare staff to reduce risks of recurrence. Since June 2007, 15 have been issued to NHS organisations in England and Wales.


The National Patient Safety Agency is a Special Health Authority of the NHS. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations.