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National Patient Safety Agency

Safety data gets NHS on board - England

7 OCTOBER 2009


Today, the National Patient Safety Agency (NPSA) publishes Organisational Patient Safety Incident Reports for each NHS trust or local health board 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 England, 92.5 per cent of all patient safety incidents result in low or no harm to the patient.  In addition, today’s figures show that 6.2 per cent of incidents are reported as moderate harm to patients, 0.8 per cent as severe harm to patients and 0.4 per cent as contributing to patient death.


The most commonly reported incident type overall is patient accident (32.8 per cent of reports), followed by treatment/procedure (10.1 per cent) and medication (9.4 per cent).


More trusts are reporting more often. 98 per cent of trusts across England provided incident reports to the NPSA – a three per cent increase compared to the previous period. There has been a seven per cent increase in the overall number of incidents reported.  For primary care, there has been a 25 per cent increase. 


The NPSA works closely with doctors, nurses, pharmacists and safety experts to analyse the incident reports and identify common safety problems which 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.”


Sir Bruce Keogh, NHS Medical Director, said: "Ensuring that patients receive care that is safe and effective with a good experience of the NHS is my top priority.  Today's figures showing that 92.5 per cent of incidents reported to the NPSA resulted in little or no harm to patients is encouraging, but we must not be complacent.


“We have learnt from industries such as aviation that scrupulous reporting and analysis of safety related incidents, particularly 'near misses', provides an opportunity to reduce the risk of future incidents.”


Cynthia Bower, Chief Executive of the Care Quality Commission, said: "Every NHS trust should be monitoring these data closely to identify patterns of poor care, spot potential problems early and to make services safer for patients. Trusts with low reporting rates need to consider whether they are tracking incidents properly. We will be following up with these trusts to check that effective safety systems are in place.”


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.”


The Bradford District Health Care Trust, an NHS organsation that provides specialist mental health services to the city and surrounding area, stresses the importance of reporting safety incidents to all of its staff.


In recent years, the trust has seen a 12 per cent increase in reporting.


The Trust's Risk Manager Lynn Pearl explained: "Incidents reported to us by our staff do not fall into a black hole and get forgotten about.


"We actively support and look to each of our service areas to learn from those incidents to ensure the likelihood of them reoccurring is minimised as much as possible.


"Every three months, we hold a safety learning forum where staff from across the trust can speak about their experiences, discuss incidents reported and share their learning.  It's all about raising awareness to reduce risks and incidents; learning from them to further improve safety for our service users."


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





Notes to Editors:




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


 Full summary reports are available for 382 out of the 392 trusts in England.


  • Ten trusts across England did not submit any reports or did not submit enough reports to be eligible for inclusion. In some cases this was due to technical problems with sending data to the NPSA. 


  • Of the ten trusts without full reports, six are primary care trusts (PCTs), two are acute trusts, and two are mental health trusts.


  • There has been a decrease in the number of organisations reporting low levels of incidents (10 reports or less) from 32 last time to 10 for this period.


  • Six strategic health authorities (SHAs) have at least one organisation that does not have a report.


  • Degree of harm (this pattern is similar to the last data release):
    • 65.9 per cent of all patient safety incidents resulted in no harm to the patient;
    • 26.6 per cent resulted in low harm;
    • 6.2 per cent resulted in moderate harm;
    • 0.8 per cent resulted in severe harm;
    • 0.4 per cent as contributing to patient death.
  • Altogether 98 per cent of NHS organisations in England reported data to the NPSA compared to 95 per cent last time.


  • There was a 25 per cent increase in reporting from primary care organisations across England.



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. 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:

The NPSA urged NHS trusts and other healthcare providers to review their patient appointment systems 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 National Patient Safety Agency (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