National Patient Safety Agency to be launched

Citation

(2001), "National Patient Safety Agency to be launched", International Journal of Health Care Quality Assurance, Vol. 14 No. 5. https://doi.org/10.1108/ijhcqa.2001.06214eab.007

National Patient Safety Agency to be launched

National Patient Safety Agency to be launched

In April, chief medical officer Liam Donaldson announced that a new agency is to be set up to boost patient safety in the NHS. The National Patient Safety Agency will run a mandatory reporting system for logging all failures, mistakes, errors and near-misses across the health service. For the first time it will introduce a streamlined approach to dealing with errors and mistakes and ensure that lessons are learnt and spread throughout the health service.

Details of the Agency are revealed in a new report Building A Safer NHS For Patients. It highlights progress made in setting up the new reporting system which was recommended by Professor Donaldson, last year. The report also recommends an improved system for handling investigations and inquiries across the NHS – ensuring they are no longer commissioned on an ad hoc basis, which can lead to lack of consistency and duplication of work.

Professor Donaldson said:

"It is estimated that 850,000 incidents and errors occur in the NHS each year – this is unacceptable.

"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."

He said that the Agency's 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. Everyone who comes into contact with the health service will have a part to play in this, from patients, to clinical staff, to managers. Over time, learning from the Agency's unique database will be the way in which one patient's bad experience will help hundreds of others. It will make the NHS a safer place for everyone that uses it.

The National Patient Safety Agency will be an independent body that will:

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  collect and analyse information on adverse events from local NHS organisations, NHS staff and patients and carers;

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  assimilate other safety-related information from a variety of existing reporting systems and other sources in this country and abroad;

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  learn lessons and ensure that they are fed back into practice, service organisation and delivery;

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  produce solutions to prevent harm where risks are identified and set out national goals and establish ways of tracking progress towards these goals.

The report also highlights other "cross-cutting" initiatives, where focusing on safety could lead to risk reduction. So far these include:

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  Reviewing the safety environment – identifying changes in care practices that could reduce risk and improve patient safety.

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  Reviewing clinical practice – in conjunction with Royal Colleges, professional organisations and specialist associations to identify high risk procedures.

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  Purchasing for safety – addressing safety as part of buying policy throughout the NHS.

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  Design for safety – seeking input from the world of design to identify previously unrecognised opportunities for improved safety.

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  Computers to reduce error – examining across a broad field the potential for computers to reduce the occurrence and impact of error.

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  Safety briefings – identifying the scope for formal "pre-procedure" safety briefings in a selected number of high risk clinical situations.

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  Risk simulations – enhancing the capacity for staff to be exposed to and handle risk in simulation laboratories.

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  Patients' role in safety – examining comprehensively the potential for patients themselves to help to promote safety and achieve safety goals.

For further information, see Building A Safer NHS For Patients available on the Internet at www.doh.gov.uk/