Within the United Kingdom (UK), unintended harm to patients occurs in around 10% of admissions or at a rate of an estimated 850,000 events a year, costing the National Health Service approximately $3.2 billion a year in additional hospital stays alone.1 The incidence and costs of litigation for clinical negligence has risen both in numbers (from about 500 in 1975 to about 6,000 in 1992) and cost (from about $1.6 million in 1975 to about $640 million in 1999)1-3 in addition to an estimated potential liability of $3.8 billion for existing and expected claims.
Two years after the publication of To Err is Human by the Institute of Medicine (IOM) that gave an assessment of medical errors in the United States of America (USA), the UK Government published a similar document called Building a Safer NHS for Patients, setting out a national plan for promoting patient safety in England and Wales and the creation of a national body to champion this cause.4
In the same year the National Patient Safety Agency (NPSA) was created to take forward the UK agenda for the development and establishment of a National Reporting and Learning System (NRLS). From the outset the NPSA has the primary aim of improving patient safety by reducing the risk of harm and error by identifying patterns and trends in avoidable adverse events so that changes can be introduced to reduce the risk of recurrence.
The NPSA’s key aims involve
- Establishing and managing a national reporting and learning system for adverse events and near misses
- Assimilating safety-related information from other organizations
- Designing solutions that prevent harm
- Setting targets and monitoring progress
- Promoting research
- Advising government ministers and others on patient safety issues
- Promoting an open and fair culture in the NHS
- Developing memoranda of understanding with other key healthcare organizations that have an interest or involvement in patient safety
One of NPSA’s key milestones during 2002 was the completion of a pilot study to test the feasibility of a single, centralized national system for reporting, coding, classifying and analyzing adverse incidents and near misses. Twenty-eight pilot sites worked to test options. Following a review of the initial pilot the project is now in the next phase of testing and development that involves the use of an electronic reporting form (the eForm) to report adverse patient safety events and near misses. Started on 31 January 2003 and initiated in 40 sites, the Testing and Development Phase is anticipated to be concluded by July 2003.
A vital part of the NPSA’s work is to identify key areas of concern for patient safety in the NHS and to develop solutions that really make a difference. The NRLS will help to identify the root causes of adverse events. Areas of concern and suggested solutions are brought to the NPSA from a variety of sources. These include NHS staff at all levels, patients, members of the public and other national and international organizations concerned with healthcare. The NPSA will look at information from any source and determine what can be done about providing a solution.
Within the UK and over the last few years, editorials in a number of anesthetic journals have raised the subject of patient safety. In doing so, a number of important patient safety issues are now being considered.
The fatal incident that occurred in Nottingham, England, in January 20015,6 following the administration of a Vinca alkaloid by the spinal route, rather than intravenously, is such an example of multiple systems breakdown. The subsequent report highlights the significance of adequate training and education and the concept of solution design is also discussed as a vehicle for reducing the risks to patients.7
Many mistakes and errors are attributed to problems in organizational aspects of care.8 Medical training focuses almost exclusively on the individual. While central to clinical care, if not balanced by an understanding of the wider process of care, this may limit the individual’s ability to be sensitive to the organizational aspects in relation to risk and quality management.
The organizational arrangements for the NPSA reflect a significant investment of expertise to embrace, develop, and take forward a number of work programs to help reduce adverse incidents through collaboration with clinicians and managers. The NPSA will ensure that examples of good practice are communicated and shared throughout the NHS, an effort pivotal to its success. The NPSA’s recognition of the work being undertaken by a number of international organizations committed to improving patient safety is also of critical importance. The NPSA also recognizes the contribution that patients and the public have to offer in reducing risk and making improvements to quality in healthcare.
Within the specialty of anesthesia, the NPSA’s interest can be demonstrated with a program of work that will consider the risk areas within the anesthetic process. This reflective piece of work is a further development following a number of reported adverse events involving foreign bodies occluding anesthetic tubes used to deliver gases to the patient. Working closely with the Royal College of Anaesthetists (RCA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), together with nursing and technical professionals involved directly and indirectly in the anesthetic process, the NPSA will consider the risks associated with anesthetics.
This assessment will enable careful and thorough exploration of the extent of risk within each step of the anesthetic process and will trace the patient journey from anesthetic pre-assessment until recovery from anesthesia. By making a pro-active, inclusive assessment of each of the steps, it is anticipated that this work will provide a clear direction as to the priorities within the specialty for any future solution development.
One further program of work will consider enhancing the operational effectiveness and patient safety in the operating theatre through the introduction of a human factors initiative (de-briefing), based upon the aviation Crew Resource Management (CRM) philosophy. As in the aviation industry, the purpose of having de-briefings will be to provide the multi-disciplinary theatre team with a background understanding of the impact of non-technical skills such as communication and decision-making on team performance.
Nick Rigg is a Communications Officer with the National Patient Safety Agency in London, England.
National Patient Safety Agency
4-8 Maple Street, London W1T 5HD, United Kingdom
Telephone: +44 20 7927 9500, Fax: +44 20 7927 9501
E-mail: [email protected]
- Department of Health. An Organisation with a Memory. Report of an Expert Group on Learning from Adverse Events in the NHS. London: The Stationary Office, 2000.
- Dingwall R, Fenn P. Risk management: financial implications. In: Vincent C, ed. Clinical Risk Management. London: BMJ Publishing Group, 1995.
- NHS Executive. FDL (96) 39. Clinical negligence costs. NHS Executive, 1996.
- Department of Health. Building a Safer NHS for Patients. Implementing an organisation with a memory. London: The Stationary Office, 2001.
- Department of Health. External inquiry into the adverse incident that occurred at Queen’s Medical Centre, Nottingham, 4th January 2001. Available on the web at: http://www.doh.gov/gmcinquiry. London: The Stationary Office, 2001.
- Department of Health. The Prevention of Intrathecal Medication Errors: A Report on the Chief Medical Office. Available on the web at: http://www.doh.gov.uk/ imeprevent. London: The Stationary Office, 2001.
- Department of Health. External Inquiry into the Adverse Incident that occurred at Queens Medical Centre, Nottingham. London: The Stationary Office, 2001.
- Reason J. Human error: models and management. BMJ 2000;320:768-770.