Half of all patient injuries are avoidable
 Around half of the incidents in which NHS hospital patients are unintentionally harmed could have been avoided if lessons from previous incidents had been learned, according to a report by the National Audit Office.
"Overall, there remains a clear need to improve evaluation and sharing of lessons and solutions. There is also a need for a clear system for monitoring that lessons are learned," says the report.
It concludes that, at the local level, the vast majority of trusts have developed a predominantly open and fair reporting culture, driven largely by the clinical governance initiatives and more effective risk management systems. There are, however, trusts where a blame culture still predominates. There is also scope for trusts to improve their strategies for sharing good practice.
In response to the encouragement to report, there have been year on year increases in the number of patient safety incidents and in 2004-05 there were around 980,000 reported incidents and near misses. Patient safety incidents are estimated to cost the NHS some £2 billion a year in extra bed days.
A retrospective study of patient records in two English hospitals found that just over 10 per cent of patients experienced an ‘adverse event’. Around half of these (5.2 per cent) were judged to have been preventable. It is widely acknowledged that there is significant under-reporting of deaths and serious incidents. Other estimates of deaths range from 840 to 34,000 but, in reality, the NHS simply does not know.
According to the NAO, trusts are now more likely to be fostering open and questioning communication between staff in teams. Almost all trusts reported that they had made progress in reducing the culture of blame; but surveys of nurses and other non-medical staff highlighted that they perceived that the blame culture continues to exist in the NHS.
The study found that although the general increase in reporting, a substantial number of incidents still go unreported (an estimated 22 per cent, mainly medication errors and incidents leading to serious harm). Reporting of near misses is also low, mainly owing to different perceptions of what constitutes a near miss.
A patient safety incident is defined as any unintended or unexpected event that causes death, disability, injury, disease or suffering for one or more patients. The most common incidents reported were: patient injury (due to falls), followed by medication errors, equipment-related incidents, record documentation error, and communication failure.
Click here for the full report. (Please note this pdf is 1.4MB)
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