21 June 2002
The National Patient Safety Agency, a department body set up a year ago to monitor medical errors in England, this week published findings from 28 pilot trusts over nine months. This showed there were 27,110 adverse incidents.
The figures point to around 680,000 incidents a year in total. But the department has acknowledged these figures are likely to under-represent the problem. It said the true occurrence was probably around a million patients a year.
The pilots were set up to test a system similar to that used in the airline industry, where staff can anonymously report near misses and errors. England's chief medical officer, Professor Sir Liam Donaldson, believes the system will move the NHS away from an organisation with a blame culture to one that learns from its mistakes.
The NPSA put this into effect this week, issuing its first alert over potassium chloride after the pilot sites uncovered 31 cases of accidental harm due to errors in administering the solution.
In the pilot sites, 135 patients died, while 2% of all the reported errors were considered 'catastrophic' or 'very serious'.
However, both Professor Donaldson and the NPSA's joint chief executive Susan Williams acknowledged that the true scale of the problem was much higher as trusts had encountered difficulties when reporting errors.
The severity of the mistakes were not classified in 62% of reports and incompatible computers meant half the hospitals could not transfer their results on to the NPSA's database. Others reported that staff found the NPSA's reporting form too complicated.
'We are going to develop over the next three months an e-based form which is much simpler to use,' Williams said.
Donaldson added: 'We have got to go back to the drawing board on some of those problems. We are looking at ways of solving that before it goes nationwide next year.'
Patients Association director Mike Stone welcomed publication of the results. 'Lessons must be learned. We are talking about people's lives,' he added.
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