The Government accepted all recommendations in An organisation with a memory and made a commitment, through the NHS Plan, to ensure that patients get high-quality care and treatment. The Government's plans to promote patient safety in the NHS are set out in the implementation document Building a safer NHS for patients, published in 2001.
The plan accepted that successful implementation depends on:
- The commitment of all NHS staff and the boards of NHS organisations
- Creation of a culture where staff feel that they can report errors, mistakes and adverse events without fear of retribution
- Establishment of clear national and local mechanisms for reporting mistakes and near misses and analysing trends
- Learning lessons to reduce risk and prevent future harm to patients
The main outcomes were as follows:
The National Patient Safety Agency
The NPSA was set up in July 2001 to co-ordinate efforts to identify and learn from mistakes. It is taking steps to promote a culture of fairness and openness within the NHS, in place of a widespread culture of blame. Health workers are encouraged to report incidents that they have witnessed without fear of reprimand. The NPSA is looking at how the public could report to it directly using the internet or a confidential hotline.
Learning system
The safety agency has set up a National Reporting and Learning System (NRLS) which will draw together reports of patient safety incidents and systems failures from health professionals across England and Wales. It will help the NHS to understand the underlying causes of problems and act quickly to introduce practical changes to prevent mistakes happening again.
Investigating errors
In the past, much confusion surrounded how investigations and inquires were carried out and many different methods were used, such as investigations, reviews, internal and external inquiries. An integrated approach across the NHS and different agencies was needed.
The National Clinical Assessment Authority (NCAA) has now been established to manage performance problems. Serious problems are referred to the General Medical Council (GMC), the main UK regulatory agency for medicine. When a patient has been harmed because of major problems with the way a service operates, the case is now referred to the Healthcare Commission (HCC), a new inspectorate launched in April 2004. Following the 2004 review of the Department of Health's arm's-length bodies, the work of the NCAA is to be brought together with the NPSA and established as a separate division within it.
Learning from research
More can be learned about the nature, causes and prevention of adverse events through properly directed research, for example of other industries where safety is a high priority, looking at patterns in past mistakes. The Department of Health is now funding a research programme that will help us understand mistakes when they happen and how they can be minimised.
The Patient Safety Research Programme builds on previous research and on work currently being funded in other countries, notably the US. The programme is also reviewing computer-based information systems that may enhance patient safety and has started talks with the Medical Research Council (MRC), to build on investment already made under the MRC programme. Projects are focusing on:
- Learning lessons from litigation arising from clinical negligence claims
- Using crisis simulations, team training and other methods to improve the ability of clinicians to respond to emergencies on labour wards
- Understanding better the engineering, psychological and social factors around safety in A&E departments and in operating theatres.
