Patient safety, a favourite with the tabloid press, is an area which is surprisingly under-discussed in health policy circles. Despite there being a specific domain around it in the NHS Outcomes Framework – “Treating and caring for people in a safe environment and protecting them from avoidable harm” – it remains low on many people’s agendas.
That patients should always be safe when they are vulnerable is a straightforward aspiration, yet translating this into reality has proved more problematic. One of the reasons for this might be that there are specific challenges related to improving patient safety – not only because it is difficult to measure, but also because patient safety incidents have historically gone unreported, or even undiscovered, for a long time. Therefore, the data on organisation patient safety in England, which were published this week, are an important element in the move towards greater patient safety within the NHS.
The data are collated by the National Patient Safety Agency (NPSA). The NPSA was set up in 2001 after a couple of disparaging reports concluded that the NHS needed to learn from, and prevent, patient safety incidents. Its purpose was to develop a national reporting scheme for incidents, disseminate safety information, and ensure that trusts were learning from their mistakes and improving their patient safety measures. The Agency has not had an untroubled time, with criticism about its cost-effectiveness, and its perceived failure to translate improved information and a greater will to ensure safety into improved outcomes for patients.
One of the most innovative and important aspects of the NPSA’s work is the National Reporting and Learning System (NRLS), which is one of the three arms of the NPSA. NHS staff report the nature and severity of patient safety incidents, such as a mistake with medication or a patient having an accident, via their local risk management systems to a central database which allows trends to be identified and alerts to be issued to the NHS when problems become apparent. The principle, borrowed from the airline industry, is that all mistakes or potential safety issues – however minor – should be reported in a spirit of openness, so they can be learned from.
It was announced that, as part of the extensive NHS reforms, the NPSA is going to be abolished and its functions will be overseen by the NHS Commissioning Board. However, it has been confirmed that the reporting of patient safety incidents will continue, which is good news, as the figures gathered prove a useful mine of information.
One of the main challenges has been defining quality when it comes to patient safety. Reporting incidents is a good thing, but is also an indication of when things go wrong. So you wouldn’t want to penalise those organisations which do report incidents, or indeed create an incentive for them to under report. The NHS Outcomes Framework has rightly identified that high reporting and low recurrence should be the key to understanding quality. High reporting indicates that processes are in place to measure performance, and that that the issue has been given sufficient priority; low recurrence means that trusts are learning from their mistakes and not repeating them.
This week’s report provides an insight into the safety profile of the NHS. The headline figures show that:
- 388,444 (69 per cent) of patient safety incidents resulted in no harm to the patient
- 136,348 (24 per cent) resulted in low harm
- 35,349 (six per cent) resulted in moderate harm
- 5,012 (one per cent) resulted in death or severe harm
These figures need to be placed in the context of the number of episodes of care delivered by the NHS – most care is safe and effective. Yet the provider-level data also reveal interesting variations in the type of incidents reported. The most common types of incident were: patient accidents – slips, trips and falls (28 per cent), medication incidents (11 per cent) and incidents relating to treatment and/or procedures (11 per cent).
It is intriguing that, when looking at trusts which specialise in treating cancer, there is such a substantial variation in the number of patient safety incidents which are linked to medication. At the Clatterbridge Centre for Oncology Foundation Trust only 6 per cent of all incidents are related to medication, whereas at the Royal Marsden NHS Foundation Trust this number leaps to 38 per cent, and at the Christie NHS Foundation Trust it is a substantial 48 per cent. With this much disparity in terms of figures, it is definitely worth asking what the underlying causes are. It would be unhelpful to take this information and make general assumptions about safety or quality of care, but it would certainly be pertinent to ask what is actually occurring on the ground to cause this result.
There are also big variations in the severity of incidents reported. For example, analysing the data for ambulance trusts, one is struck that in the West Midlands Ambulance Service NHS Trust the number of safety incidents which were ‘severe’ or ended in death was only 0.4 per cent, whereas in the South Western Ambulance Service NHS Trust, 14.5 per cent of safety incidents were classed as severe or ended in death. A discrepancy like that, and there are many such as this within these figures, is certainly worth exploring further.
Similarly, when looking at specialist orthopaedic providers, it is notable that the percentage of incidents which qualify as ‘moderate’ or ‘severe’ vary considerably. Only 11 per cent of the patient safety incidents at the Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust were moderate or severe, compared with 14 per cent for the Nuffield Orthopaedic Centre NHS Trust, and a surprising 38 per cent for the Royal Orthopaedic Hospital NHS Trust. It would be unhelpful and simplistic to decry the latter provider as more dangerous, but it should raise further questions which require explanation, such as whether the Trust takes on more difficult cases, or whether it has good protocols in place to learn from previous safety incidents.
Ultimately, this is the most powerful consequence of the figures which were released this week. They raise questions which should be answered, and enable providers to compare themselves with others like them. Most importantly, they should help providers learn from their mistakes. These data therefore shine a much-needed spotlight on an essential area of care which is too often overlooked.