20 April 2001
All NHS organisations will be required to report every error and 'near miss' to the National Patient Safety Agency. It will record and analyse the information and, by highlighting themes and problems, should spread good practice across the health service. Negligence claims cost the NHS about £400m a year.
The agency will work with other bodies, such as the medical royal colleges, to review clinical practices and it will also examine the role computers could play in eradicating errors from routine procedures. This could include ensuring the correct amount of drugs are administered or that dangerous combinations of medicines are never given to patients.
Patients' role in their own safety will also be researched by the agency, which is due to begin work in July.
Chief medical officer Liam Donaldson said the emphasis would not be on apportioning blame but on ensuring errors were not repeated. Whistleblowers would be protected under the new system, which is based on the reporting of adverse incidents in the aviation industry.
'It is estimated that 850,000 incidents and errors occur in the NHS each year – this is unacceptable,' said Professor Donaldson.
'While it is an inescapable fact of life that people make mistakes, there is much we can do to reduce their impact and so reduce risks for patients. The new agency will be the catalyst for this.
'Its system of identifying, recording, analysing and reporting adverse events will be at the heart of a shift to a more blame-free, open NHS, where lessons are shared and learnt.'
British Medical Association consultants' leader Peter Hawker recognised that mistakes can be made, often because modern health care is complex and performed in a pressured environment. But he added that the initiative would work only if the blame culture in the NHS were abandoned.
'Unless we have some degree of confidentiality and protection for the individual clinician, it will be difficult to create a climate in which we can all learn from experience,' he said.
PFapr2001
