Editorials

After the abolition of the National Patient Safety Agency

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c6076 (Published 03 November 2010) Cite this as: BMJ 2010;341:c6076
  1. John Scarpello, consultant physician (emeritus)
  1. 1University Hospital of North Staffordshire NHS Trust, Stoke on Trent ST4 6QG, UK
  1. john.scarpello{at}virginmedia.com

The patient safety incident database must continue as a source of national learning

In July this year, the review of arm’s length bodies announced that the National Patient Safety Agency (NPSA) is to be abolished.1 The NPSA was established as a special health authority in 2001, with the core function of promoting a culture of reporting and learning from adverse events. The first division of the NPSA, Patient Safety, will move to the new NHS Commissioning Board; the second, the National Clinical Assessment Service, will become self funded; and the third, the National Research Ethics Service, will be considered as part of the review of research regulation. Confidential inquiries will be managed by the Healthcare Quality Improvement Partnership.

The NPSA established the NHS Reporting and Learning System in 2003. It provides a unique national database for patient safety incidents. Healthcare staff report patient safety incidents and concerns to their local organisation, which investigates, but importantly these incidents are also uploaded to the reporting and learning system from hospitals’ and primary care trusts’ risk management systems. The reporting and learning system is now the most comprehensive national reporting system for patient safety in the world, with more than five million reports. More than 80 000 incidents are reported by NHS staff every month.

In 2006, Safety First recommended ways to improve learning from the database,2 and in response the NPSA developed a rapid process to analyse new incidents and issue advice to the NHS on reducing harm. All incidents reported as resulting in severe harm or death are reviewed so that any wider learning for the NHS can be identified quickly, and the database is consulted to seek evidence of similar incidents.3 The national database highlights when a single event reported in isolation reflects a more common system weakness, for which solutions are available for general benefit. These rapid response reports (RRRs) are issued in England through the Department of Health central alerting system, and healthcare providers are required to act within a specified time.

The reporting and learning system also provides evidence on the proportion and severity of incidents involving patient safety among the different healthcare settings. Otherwise, such information is limited and was described as poor by the National Audit Office.4 We have little idea how many of these incidents occur and how serious they are, but figures from the database suggest that serious incidents are much lower than the widely quoted figure of 10% of hospital admissions being associated with an adverse event.5

In addition to alerting the service to new risks, the NPSA improved patient safety across the NHS through safety campaigns and training packages. Many of these are now accepted as standard practice. Examples include the Clean Your Hands campaign; the World Health Organization’s adaptation of the surgical checklist; root cause analysis training; standard crash call telephone numbers for hospitals; standard design for wristbands; and safer medication alerts for potassium chloride, methotrexate, and anticoagulants.6

The current state of the public finances requires government to make widespread efficiency savings across all departments and areas of public life. Although the NHS budget will increase in real terms, as set out in the recent spending review,7 huge pressures on cost will come from an ageing population, the evolving complexity of modern healthcare, and escalating costs of new treatments. Thus efficiency savings must be achieved across the NHS, and this includes the NPSA. When first established the agency had a generous budget but a confused strategy. The restructure after Safety First was too complex, as identified by the recent review.1 It is also separate from other bodies that influence patient safety, such as the Medicines and Healthcare Products Regulatory Agency and Health Protection Agency.

Oversight of all agencies and regulators that affect patient safety should be a prime objective of the new NHS board. Although patient safety is the responsibility of local providers, it is strengthened by reference to national data. We must not lose the experience gained in the critical analysis of incidents reported to the national database and the national learning that follows. The board should require more complete reporting of incidents by clinical staff from all healthcare settings. At present, reporting from primary care is low,8 yet this is where most contact with patients occurs and many errors are made, such as delayed diagnosis of cancer.

In its short life the NPSA succeeded in raising awareness across the NHS. Training in understanding how human factors influence patient safety is now standard practice, as is the investigation of incidents by root cause analysis and knowledge of the importance of changing systems to reduce risk. Patient safety is the responsibility of all members of healthcare teams. Those commissioning services should seek evidence of the safety of ongoing practice and ensure that risk assessments are carried out before introduction of new services. Some areas of patient safety are best managed nationally. Abolishing the reporting and learning system national database and its clinical review team would be a major error that would adversely affect patient safety.

Notes

Cite this as: BMJ 2010;341:c6076

Footnotes

  • Practice, doi:10.1136/bmj.c5469
  • Practice, doi:10.1136/bmj.c5884
  • Competing interests: The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; JS was deputy medical director at the NPSA from 2005 until retirement from the NHS in 2010.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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