In 2000, the Chief Medical Officer (CMO) chaired an expert group to investigate patient safety in the NHS. The group's conclusions and recommendations were published in the report An organisation with a memory, which attracted much interest at home and abroad.
The group set out to review the scale and nature of serious failures in the NHS, to examine its capacity to learn from them and to recommend measures to minimise repeated cases. The group used evidence and experience from sectors outside health, including the aviation industry and academic research.
The report revealed that the NHS had no systematic way of identifying, learning from and dealing with things that went wrong. Without any organisational memory, history is doomed to repeat itself: the error that causes a bad experience for one patient would never prevent future patients from being harmed. The key problems were:
Data
There was no consensus on what to report and no proper links between different reporting systems.
Analysis
Available information was not being used effectively and there was no analysis of information across different systems.
Investigations
There was little clarity about when an inquiry or investigation was appropriate and no clear guidance on how to conduct either. There was also concern about how inquiries and investigations were followed up.
Understanding errors
There was little understanding or research into the nature, causes and prevention of adverse events or appreciation of the 'system approach' , which looks at how and why a system fails.
The blame culture
There was evidence of a 'blame culture' in the NHS. When things went wrong, the response was often to blame one or two individuals, who were then subjected to disciplinary measures or professional censure.
Near misses
There was no mechanism in place to record things that went wrong but did not result in significant harm. Research suggests that for every one adverse event there is likely to be 300 near misses, a valuable source of learning.
Learning from failure
Organisations were unlikely to learn effectively from failures. Too often, lessons were not shared across the NHS. Existing systems took a long time to report and even longer to implement and follow up. Insufficient effort was being made to target high-risk clinical procedures and no one had looked into developing solutions to reduce the risk involved in these procedures.
National targets
In some areas of clinical practice, regular patterns of error are recognised. The report identified four such areas and set targets for improvement:
- Badly administered spinal injections
- Negligence and harm in obstetrics and gynaecology
- Serious errors in the use of prescribed drugs
- Suicides of mental health in-patients
Report recommendations
- Introduce a mandatory reporting scheme for adverse events and specified near misses.
- Introduce a scheme for staff to report these in confidence
- Encourage a reporting and questioning culture in the NHS
- Introduce a single, overall system for analysing mistakes, and disseminating lessons from them
- Make better use of existing sources of information
- Improve the quality and relevance of NHS investigations and inquiries
- Undertake a programme of basic research into adverse events in the NHS
- Make full use of new NHS information systems to help staff learn from mistakes
- Act to ensure that important lessons are implemented quickly and consistently
- Identify and address specific categories of serious errors that reoccur
