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National Patient Safety Agency

Safety data gets NHS on board - Wales

7 October 2009


Today, the National Patient Safety Agency (NPSA) publishes Organisational Patient Safety Incident Reports for each NHS organisation across England and Wales.  These have been designed to be used by boards to compare their reporting profile with similar NHS organisations and set priorities for local action.


The Organisational Patient Safety Incident Reports summarise incidents reported by frontline NHS staff that have occurred between October 2008 and March 2009, and reported to the NPSA by 30 June 2009. 


Today’s figures show that across Wales 90 per cent of all patient safety incidents result in low or no harm to the patient.  The most common problems are associated with patient accidents (36.4 per cent).


The NPSA works closely with doctors, nurses, pharmacists and safety experts to analyse the incident reports and identify common safety problems which may need action across the NHS.  In the past six months this has included new guidance on oxygen safety, the clinical use of suprapubic catheters, and how delayed appointments could lead to blindness amongst patients with glaucoma.


Chief Executive Martin Fletcher said:  “National reporting and learning means that the lessons learnt from safety problems are not trapped within the walls of one facility but can be spread across the NHS to prevent similar events occurring. 


“More reports do not mean more risks to patients. Indeed quite the reverse. These data are sound evidence of an improving reporting culture across the NHS.  Frontline staff are more likely than ever to raise safety concerns much more openly.


“Only with strong leadership from boards will we succeed to make patient care even safer. These organisational reports will help boards review their local approaches to patient safety. This will help build an even stronger safety culture of reporting and learning to prevent harm to future patients.”


Chief Medical Officer for Wales Dr Tony Jewell said: “I welcome the publication of these reports and expect NHS organisations to study the reports carefully.  This work will complement their efforts as part of the 1000 Lives campaign to continually improve patient care and safety. 


“Every year, thousands of patients receive high quality, safe and effective treatment, but in a modern health system – where increasingly complicated procedures are being undertaken – mistakes can and will still happen.


“It is important that every incident is reported so we can learn from these errors and reduce the risk of these happening again.  It is worth pointing out that these figures also include incidents which have not resulted in any harm to patients, but if staff hadn’t identified a risk, it may have led to harm.


“The NHS in Wales takes patient safety extremely seriously and we were one of the first in the UK to introduce a major initiative to improve safety.  The 1000 Lives campaign aims to reduce avoidable risk to patients by implementing new ways of working and techniques including better management of medicines, reducing healthcare associated infections and surgical complications, and improving general medical and surgical care.


“Only last week was this work commended by the NPSA at a conference in Swansea to share experiences and showcase best practice to drive forward improvements in patient care.


“At the conference, NHS Wales Chief Executive Paul Williams emphasised the importance for the new health boards to continue to have clinical quality and reducing harm to patients at the heart of everything they do.”


Dr Jacinta Abraham is Consultant Clinical Oncologist at the Velindre Cancer Centre, part of Velindre NHS Trust which serves Cardiff and south east Wales.   She said: “Each month we hold Serious Clinical Incident Forum groups which aim to look at all safety incidents that have occurred within the Velindre Cancer Centre and review them to ensure lessons are learnt within a no blame culture.  The aim is to improve standards of care and safety.  


“We also hold twice yearly open sessions for clinical staff.  The aim here is to inform and educate all clinical staff about a particular incident and what to look out for in the future to order to avoid harm to patients.  The meetings also allow our staff to give their opinions and thoughts about issues.”


Dr Peter Higson, Chief Executive of Healthcare Inspectorate Wales, said: "Learning from incidents should be at the core of everything that organisations do to improve patient safety.  Any organisation that fails to understand that simple message is destined to repeat its mistakes.  The ability of organisations to capture information about incidents and make changes to improve patient safety is one of the most important factors we consider when reviewing organisations.”


Katherine Murphy, Director of the Patients Association, said: “We welcome an increase in reporting – we can’t truly face up to the patient safety challenge until we know what the real burden of harm is.  I hope those organisations still lagging behind in reporting will address the issue with vigour. The high reporting organisations are proof that there really is no excuse. Patients shouldn’t have to face a postcode lottery on patient safety.”


For a full breakdown of the number of incidents reported by organisations, visit the Organisation Patient Safety Incident Reports web page.





Notes to Editors:


1. Key statistics and facts about Organisational Patient Safety Incident Reports


  • In Wales:
    • 67.9 per cent of all patient safety incidents resulted in no harm to the patient;
    • 22.1 per cent resulted in low harm;
    • 8.2 per cent resulted in moderate harm;
    • 1.4 per cent resulted in severe harm;
    • 0.4 per cent as contributing to patient death.


  • 90 per cent of NHS organisations across Wales provided a report to the NPSA.


  • There has been a decrease in the number of organisations reporting low levels of incidents (10 reports or less) from 13 last time to seven for this period across Wales.


  • Seven organisations did not report any incidents or not enough incidents to be eligible for inclusion, all of which were local health boards.


  1. Media enquiries to the NPSA Press Office:

Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk; Dinah Lartey – 020 7927 9351 / dinah.lartey@npsa.nhs.uk; Out of hours – 0788 411 5956


The National Patient Safety Agency is an Arm’s Length Body of the Department of Health and works in Wales. 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. For more information visit: www.npsa.nhs.uk


Definition of a patient safety incident - a patient safety incident is any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care.    


The NPSA manages the National Reporting and Learning System (NRLS) which collects voluntary staff reports on a vast range of incidents such as those related to medicines, surgery, medical devices, mental health and other aspects of the delivery of healthcare from all NHS healthcare settings in England and Wales.  Over three million patient safety incidents have been reported to the NRLS since its inception in November 2003.


Reports to the NRLS are analysed with expert clinical input to identify common hazards and to make recommendations to local NHS organisations to mitigate these risks and improve the safety of patient care.  In short, information from reported incidents helps the NHS understand why things go wrong and how to stop them happening again.  Within a local NHS organisation, a serious event may be perceived as a one-off.  Reporting to the NRLS can reveal similar incidents in other parts of the NHS and can also help identify learning from incidents in different organisations.


Examples of recent NPSA-led patient safety initiatives


New oxygen safety guidance

After 281 serious were reported to the NPSA between December 2004 and June 2009, the NPSA worked with the NHS to develop guidance aimed at ensuring safer systems are in place to treat patients needing oxygen.  The alert was issued to all NHS acute, community and mental health organisations, as well as the independent sector.  Of these incidents, poor oxygen management appears to have caused nine deaths and may have contributed to a further 35 deaths.


Hospitals alerted to risks of inserting suprapubic catheters incorrectly

The NPSA worked with the NHS to develop guidance to hospitals concerning the risks of using suprapubic catheters after a number of patients suffered severe harm or fatal injuries as a result of error.


The guidance comes after three patients died and seven were severely harmed after the devices were incorrectly inserted.


Suprapubic catheters are used to drain patients’ bladders when they are blocked or when a urinary catheter cannot be inserted.  They may also be used in patients with spinal injuries or neurological conditions such as multiple sclerosis and for some undergoing surgery. 


Delayed appointments can lead to blindness: NPSA report

The NPSA urged NHS organisations and other healthcare providers to review their patient appointment and ensure all patients with glaucoma are treated appropriately and on time.  The advice came as new reports to the NPSA revealed that 135 patients with glaucoma experienced cancellations or delays to their follow up appointments – 44 of these resulted in partial loss of  eyesight,  including  13  patients  who  went completely blind in one or both eyes. In some cases, patient appointments had been delayed by as much as 18 months.


WHO safe surgery checklist

The NPSA issued a patient safety alert on 15 January 2009. The alert required all healthcare organisations to implement the WHO Surgical Safety Checklist for every patient undergoing a surgical procedure. The final implementation date is February 2010. This follows dramatic results from a year-long global pilot of the WHO checklist in eight countries.


For further information visit www.nrls.npsa.nhs.uk/alerts



Patient Safety First Campaign

The NPSA is co-sponsoring the Patient Safety First Campaign which is working with local NHS organisations to support implementation of initiatives such as the WHO safe surgery checklist and is providing tools and supports for boards to promote strong local leadership.


See www.patientsafetyfirst.nhs.uk