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National Patient Safety Agency

NPSA to lead on new patient safety initiatives following Lord Darzi’s Review

30 June 2008


The National Patient Safety Agency warmly welcomes Lord Darzi’s NHS Next Stage Review which firmly places the safety and quality of patient care at the heart of the NHS over the next 10 years.


There are a number of key initiatives which the NPSA will be taking forward as detailed in the report.  These include working with interested parties to develop a set of Never Events for the NHS.  Never Events are patient safety incidents which seriously harm patients, are preventable using current knowledge and are of significant concern across the NHS and to the public. For example, wrong site surgery which causes significant harm.  Drawing on experience in the US, we will work closely with Primary Care Trusts to test the implementation of a set of Never Events in the NHS, in order to make further gains for patient safety.


Preventing harm to patients is at the core of patient safety. The NPSA will lead a series of initiatives to ensure that proven safety interventions are widely implemented across the NHS.  Starting with a focus on reducing blood stream infections, the initiative will be based on a hugely successful model led by Professor Peter Pronovost from the John Hopkins Quality and Safety Research Group. This achieved a large and sustained reduction in rates of catheter-related bloodstream infections across more than 100 intensive care units in Michigan, United States of America.


Speaking about the NHS Next Stage Review, Martin Fletcher, Chief Executive at the National Patient Safety Agency said: “Lord Darzi strongly affirms the place of patient safety at the heart of a 21st century NHS.  Safety initiatives such as Matching Michigan will make sure that we are helping the NHS to close the gap between what we know and what we do. Never Events will allow us to test new ways to embed patient safety as an integral part of the way health services are commissioned and managed. We look forward to working closely with the NHS on these important safety developments.”


Dr Peter Pronovost, Professor and Director Johns Hopkins Medicine Anaesthesia and Critical Care Medicine Quality and Safety Research Group USA, said:  “Polio used to kill hundreds of thousands of people worldwide each year. Deaths from polio are now rare. Catheter related blood stream infections can be reduced and eliminated as polio has been. England could be the first country to eliminate these infections using a programme that nearly eliminated these in Michigan in the USA.  I am heartened that England shows the courage and leadership to do this.”





Notes for editors:


  1. Media enquiries to Amelia Lyons in the NPSA Communications Department on 07500 224 240, amelia.lyons@npsa.nhs.uk or Paul Cooney on: 0207 927 9351, paul.cooney@npsa.nhs.uk

  2. Professor Peter Pronovost from the John Hopkins Quality and Safety Research Group.   Further information on this study can be found at: Pronovost P et al An Intervention to Decrease Catheter-Related Bloodstream infections in the ICU N Engl Jl Med, 2006; 355: 2725-2732.

  3. The National Patient Safety Agency encompasses the National Research Ethics Service, Patient Safety Division and the National Clinical Assessment Service. Our vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. Each division works within its sphere of expertise to improve patient outcomes.