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February 2012

Patient Safety – Where to now for a safer NHS?

Financial redress is often one of a number of concerns for many of our clients who seek advice in respect of medical accidents.

They also seek answers regarding why their healthcare went wrong leaving them more damaged and in particular reassurance that it won’t happen again to someone else.

It has been helpful in the last 10 years to point to the work of the National Patient Safety Agency which was implemented as an organisation to reduce the risk to patients receiving NHS care and to improve patient safety.

The NPSA has done this by collecting data on patients' safety and incidents, identifying risks and recommending actions. They have promoted effective local resolution regarding concerns about the health practitioners and they have developed safety strategies for the NHS to enhance public confidence.

National Reporting and Learning Service (NRLS)

The NRLS established in 2003 is at the heart of the Patient Safety Division of the NPSA.

Through this system, transparency and openness regarding mistakes is advocated in healthcare staff. The old style ‘closing of ranks’ is actively discouraged.

Healthcare staff are encouraged to report so called ‘adverse events’. The NRLS campaigns to ensure that healthcare workers realise this will benefit both them and patients in the long term. The NRLS invites the reporting of mistakes so that lessons can be learned.

When a patient safety incident happens, NHS staff in England and Wales can make a confidential online report via their local reporting system. All staff are actively encouraged to report all incidents whether they result in harm to the patient or not. The reports are fed into a database. Clinicians and safety experts analyse the reports to identify common risks and opportunities to improve patient safety.

Regular ‘alerts’ are issued to address specific safety risks and tools to build a strong safety culture.

Current alerts on the NRLS website range from :

Keeping newborn babies with a family history of MCADD safe in the first hours 26 October 2011 Alert
The adult patient’s passport to safer use of insulin 30 March 2011 Alert
Reducing the harm caused by misplaced nasogastric feeding tubes in adults    

Healthcare organisations are provided with feedback and guidance to improve patients' safety.

Patients and the public can also currently report on patient safety incidents.

Whilst individual reports are not investigated, public concerns are recorded and the information used to improve patient safety.

The NRLS is widely acknowledged to be the largest source of patient safety incident data in the world.

In addition, the NPSA has commissioned major national reports on, for example issues such as maternal and new born clinical outcomes, and publishes on it’s website annually, reports on patient safety incidents for all Trusts and Local Health Boards in England and Wales.

However, as part of a tranche of wide ranging reforms to the NHS implemented by the coalition government the NPSA is one of the ten ‘arms length bodies’ to be abolished.

Responsibility for patients' safety will be moved to the new NHS Commissioning Board. This organisation will have the role of allocating resources as well as the dual role of patient safety. Many have pointed to the potential for conflict of interest, by linking patient safety to funding.

The move however is already well underway with transfer of the operational management of the NRLS to a London Hospital Trust, Imperial College Healthcare being approved on 30/11/2011.

It is proposed that this will be a temporary transfer for two years. During the two year period a full tendering process will be developed by the NHS Commissioning Board. It is said that this will “identify the future specification of requirements for a national system to capture and realise patient’s safety incident data”.

Clearly there are moves afoot to change the scope and focus of the NRLS.

The independent sector had also agreed to feed in their risk reports to the NRLS and IT was set up for it, which is all now on hold. This is a real concern as this could potentially prevent the recurrence of something like the current PIP implant problem.

There must be real concern that the progress made in the last ten years by the NPSA in improving patients' safety by being an ‘organisation with a memory’, having the resources to track and learn from it’s mistakes will be lost. That we will revert to old style practices of patients being misled when things go wrong.