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National Patient Safety Agency

Safety in numbers - NPSA publishes new local patient safety incident data

Friday 6 March 2009


NHS staff are more likely than ever to raise a patient safety concern as new data, released today by the National Patient Safety Agency (NPSA), demonstrates an upward trend in safety reporting.


Today (06 March) the NPSA will begin publishing Organisation Patient Safety Incident Reports from each NHS trust or local health board in England and Wales. 


The NPSA’s Reporting and Learning database began recording patient safety incident reports in 2003.  Since then the NPSA has encouraged all healthcare staff to report to the database to help the NHS understand why things go wrong, and how to prevent them happening in the future.


The latest data show that over 65% of all patient safety incidents result in no harm to the patient.  The most common problems are patient accidents, followed by treatments and procedures and medication related incidents.


Speaking about the release of the Organisation Patient Safety Incident Reports, Martin Fletcher, Chief Executive, NPSA, said: “If we don’t know where the problems are, then we can’t fix them.  That is why we are so pleased that more and more staff are reporting safety concerns.  This shows that there is a much greater awareness of patient safety amongst NHS staff.  We believe that an organisation with a high reporting rate is much more likely to have a strong commitment to patient safety and high safety standards.


“We will never be able to stop human beings making mistakes, but we can try and ensure that such errors do not translate into patient harm. This is why reporting of incidents even when there is no harm to patients is important.  These incidents represent the best opportunity for learning because NHS staff are raising a safety concern before anyone gets hurt.”


The publication of Organisation Patient Safety Incident Reports aims to encourage greater awareness of patient safety and to improve the quality of local and national reporting from all healthcare staff, as part of embedding strong patient safety standards in all NHS organisations.


Welcoming the publication, Professor Sir Bruce Keogh, NHS Medical Director, said:


“Whilst there is obvious value in reporting incidents where patients have suffered harm, it is just as important that we encourage people to report even more incidents that highlight potential risk to patients so that they can be analysed and corrected well before anyone comes to harm.”


Sir Robert Naylor, Chief Executive, University College Hospital NHS Foundation Trust, said: “Publishing this data will help to improve patient safety.  The sharing of reports will enable trusts to learn from one another to ensure similar incidents do not occur in the future.  At UCH we are continually introducing initiatives designed to improve the quality of care for patients such as our recent Safety Improvement Project which aims to minimise the risk of falls.”


Cynthia Bower, Chief Executive of the Care Quality Commission said: “Ensuring that services are safe is at the heart of the work of the Care Quality Commission.  Knowing about when things go wrong helps us to understand the reasons for failings in patient safety and helps everyone to improve standards. It is particularly good to see that more staff are reporting safety concerns, demonstrating their commitment to patient safety.”  


Dr William Moyes, Executive Chairman of Monitor said: “Monitor welcomes the increased transparency that publication of trust-level data on incident reporting will offer. For the first time the Boards of trusts will be able to examine closely the levels and patterns of reporting in their own hospitals and how this compares with other hospitals. This will add to their understanding of its performance and will enable boards to take action to remedy areas where there might appear to be problems.  This is an important step towards developing the rounded understanding of the quality of services that a board needs if it is to discharge properly its responsibility for the performance of the hospital.”


Katherine Murphy of the Patients Association commented: "This is long overdue. Patients need local information on which to base their treatment choices. It needs to be in an easily understandable and accessible form or patients cannot give truly informed consent and make comparisons."


 View the Organisation Patient Safety Incident Reports





Notes to editors:


  1. Media enquiries to Sara Coakley in the NPSA Press Office on 020 7927 9580 or  sara.coakley@npsa.nhs.uk. Out of hours: 0788 411 5956.

  2. The Organisation Patient Safety Incident Reports are based on reports by NHS organisations in England and Wales for the period April 2008 to September 2008 will be available on Friday 06 March on www.npsa.nhs.uk

  3. The National Reporting and Learning System (NRLS) 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.  Over three million patient safety incidents have been reported to the NRLS since its inception in November 2003.

  4. 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.

  5. In November 2008, the NPSA sought feedback from the NHS on the proposed publication of organisational level incident data.  Feedback indicates that NHS and other colleagues support the change.  84% of respondents to our on-line survey agreed that publication should go ahead.

  6. 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. For more information visit: www.npsa.nhs.uk.