Adverse incidents in NHS are still under-reported

BMJ 2006; 333 doi: (Published 06 July 2006) Cite this as: BMJ 2006;333:59
  1. Adrian O'Dowd
  1. London

    Under-reporting of adverse incidents and near misses is still a problem in the NHS and a barrier to improving patient safety, a new report says.

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    Almost a million patient safety incidents and near misses happened last year in England's NHS, but a fifth of incidents and two fifths of near misses are estimated to go unreported, it says.

    The report, from the parliamentary public accounts committee, claims that the National Patient Safety Agency has failed so far in its five year existence to secure accurate information on serious incidents and deaths and to help the NHS learn from previous experience.

    There were 974 000 patient safety incidents and near misses in 2004-5 recorded on NHS trusts' reporting systems. Trusts estimate that an average of 22% of incidents and 39% of near misses go unreported—mainly medication errors and incidents leading to serious harm.

    The MPs investigating the issue found that doctors are less likely to report an incident than other groups of staff and recommend that trusts evaluate their own levels of under-reporting and target specific training at those groups of staff that are less likely to report.

    The Department of Health established the National Patient Safety Agency in July 2001 to collect and analyse information; assimilate other safety related information from a variety of existing reporting systems; learn lessons; and produce solutions.

    A key target for the agency was to develop a national reporting system by December 2001. The national reporting and learning system was three years late in being linked to trusts' own reporting systems, and it overspent. In addition, the parallel, anonymous, electronic reporting system was only available from September 2004.

    Edward Leigh, a Conservative MP and chairman of the committee, said of the recorded incidents, “These statistics would be terrifying enough without our learning that there is undoubtedly substantial underreporting of serious incidents and deaths. To top it all, the NHS simply has no idea how many people die each year from patient safety incidents.

    “What this points to are two related and deep seated failures. One is the failure of the NHS to secure accurate information on serious incidents and deaths. The other is the failure on a staggering scale to learn from previous experience.”

    There has been some notable improvement at NHS trust level in developing a more open and fair reporting culture, the report says. However, underreporting of incidents remains a problem and trusts do not do enough to inform patients when something does go wrong. Only 24% of trusts routinely inform patients involved in a reported incident.

    Insufficient progress has been made to achieve the department's plans to guarantee a safer NHS for patients, the report concludes.


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