Website of the Department of Health

In February 2004, the National Patient Safety Agency produced a risk assessment of spinal procedures with existing safeguards and came up with three new connector designs.

• Download New designs (PDF, 39K)

Negligence and harm in obstetrics and gynaecology
Report target: Negligent harm in obstetrics and gynaecology, which may account for over 50% of the annual NHS litigation bill, to be reduced 25% by 2005.

Errors affecting newborns are always tragic and can lead to a lifetime of care and support. Evidence suggests that in order to reduce risks, health professionals need to focus on:

The National Institute for Clinical Excellence (NICE) has issued guidelines on electronic fetal monitoring, induction of labour, antenatal care and Caesarean section. The Department of Health has commissioned further clinical guidelines for the management of routine labour, the postnatal period and postnatal depression. Alongside the National Service Framework, these guidelines are designed to improve maternal and neonatal outcomes.

The department's Patient Safety Research Programme has commissioned a number of research projects, including a review of cases in which errors have occurred and resulted in litigation, as well as commissioning separate research to check the quality of current practices in obstetric emergencies, and audit maternity training.

Serious errors in the use of prescribed drugs
Report target: The number of serious errors in the use of prescribed drugs, which can account for 20% of all clinical negligence litigation, to be lowered 40% by 2005.

Nearly two million prescriptions are written in England every day. Although prescribing standards are high, it is inevitable that mistakes occur. Some of the most serious incidents happen because a patient has been given the wrong drug. One of the most common causes of this mistake is where different medications have been produced in identical packaging.

In 2002, the NPSA issued a Patient Safety Alert to make medical professionals aware that potassium chloride and saline solution are packaged in almost identical ampoules (capsules). It also explained how to prevent accidental overdoses of potassium chloride.

At the beginning of 2004, the Chief Pharmaceutical Officer issued a medication safety report that identified common sources of errors and practical ways to improve safety. The  report, Building a safer NHS for patients: Improving Medication Safety, was launched by Lord Warner. Among other things, it offers an analysis of the causes and frequency of medication errors; case studies in community and acute care settings; examples of good practice and detailed recommendations for the prescribing, dispensing and administration of a range of high-risk drugs.

For example, this report notes that the true incidence of medication errors, within the NHS and elsewhere, is not known because of low reporting rates and the many barriers to reporting. In response, mechanisms have now been set up to create more data from the NPSA's national reporting and learning system and a range of other sources,  which will provide a clearer insight into the nature of patient safety incidents.

As further means to understand the true extent of medication errors, and action that will help to further reduce these, the Department has commissioned specific research to determine the frequency of medication errors of different magnitude, at different stages in the patient journey, and identify plausible interventions aimed at the different sources of error.

• Building a safer NHS for patients: Improving Medication Safety

Design for safety
The report Design for Patient Safety, jointly commissioned by the Design Council and the Department of Health, was published in February 2004. It showed that doctors and nurses need products that are simple to use, systems that are easy to understand and a working environment that promotes safety.

• Design for patient safety

In the past, healthcare products and services have been designed without enough knowledge about the context of their use, or the needs of the people who use them. Design for Patient Safety outlined the 'systems design' approach that can help build safety into NHS decision-making, as well as a number of practical ways in which design can be used to avoid errors, for example:

Suicides of mental health in-patients
Report target: Suicides of mental health in-patients through hanging from non-collapsible bed or shower curtain rails to be cut to zero by 2005.

For a number of years, the most common method of suicide by mental health patients in acute psychiatric units has been hanging using curtain or shower rails. Professor Louis Appleby, national director for mental health, requested that all NHS Trusts take out all non-collapsible structures such as bed, shower and curtain rails in acute psychiatric wards and by April 2002 all were removed.

Since then there has been a fall in the number in-patient suicides in England. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness expects final figures to show a fall from 215 to 156 suicides per year from 1997 to 2002, with hangings falling from 49 to 31 per year.