| The National Patient Safety Agency was set up following the publication
of two reports on patient safety in the National Health Service: “An
organisation with a memory” and its follow-up, “Building
a safer NHS for patients”. The reports highlighted research which
suggested that around 10 per cent of patients admitted to United Kingdom
acute hospitals experience some kind of incident that might threaten
their safety, and that up to half of these could have been prevented.
Findings in the United States, Australia, New Zealand and Denmark have
suggested similar error rates. The reports noted, however, that in the
UK as well as in many other countries, little systematic learning resulted
from incidents or failures in health care.
The international evidence tells us that in complex health care systems
things can, will and do go wrong. “An organisation with a memory” concluded
that the best way of reducing error rates is to target the underlying
systems failures, rather than to take action against individual members
of staff, since most incidents result from weaknesses in systems and
processes rather than the acts of individuals. This thinking reflects
the work of Dr Lucian Leape from the Harvard School of Public Health,
who has demonstrated that professionals will make errors in imperfect
systems however hard they try not to, and that punishing people for their
mistakes does not reduce error rates.
Both these conclusions have informed our development of the National
Reporting and Learning System (NRLS). The new system — the first
of its kind in the world — will co-ordinate the reporting of patient
safety incidents nationally and, more importantly, improve the ability
of the NHS to learn from an analysis of these incidents.
Of the 850,000 incidents that are likely to occur annually in hospitals
in the UK, around one-quarter involve medication errors so it is vitally
important that pharmacists working both in hospitals and the community
are involved in patient safety incident monitoring and analysis. Although
most of the research to date has focused on incidents in acute care,
many of the underlying contributory factors relate to all health care
settings.
Local schemes
The safe medication practice team at the NPSA has visited a number of
organisations that are already doing good work locally. This includes
an anonymous paper-based reporting system for prescribing and dispensing
events called Sharing Actions Following Events Reporting (SAFER), which
was set up by a community pharmacist in Gwent and receives about 30
reports a month from 130 pharmacies. At the Royal Liverpool and Broadgreen
University Hospital Trust, the pharmacy department found significant
continued on-ward preparation of potassium infusions using potassium
chloride ampoules, despite all of the published risks. In the autumn
of 2001, the hospital ordered the withdrawal of potassium ampoules
from all clinical areas and issued a policy statement that promoted
the safe intravenous administration of potassium to correct hypokalaemia.
The NPSA has since issued an alert on this
subject.
The NRLS has been designed to build on this local activity and the system
has been developed to be compatible with all the major commercial local
risk management systems used in most NHS organisations. This means that
incident information that was previously only collected locally can be
gathered to track national trends in a seamless way. The system depends
on two main features for its operation:
• An NPSA dataset — a standard national framework used to gather
patient safety incident information and ensure optimum learning
• An electronic reporting form transmitted via NHSnet, Health of Wales
Information Service or the internet, for organisations without a commercial
local risk management system, or for those staff who only wish to report
independently of their organisation
The NPSA expects that hospital-based pharmacists will report through
their local NHS system while independent community pharmacists will use
the electronic reporting form. The national and regional multiple pharmacy
groups that already report incidents internally are expected to link
up with the NRLS via corporate systems in the head office. Whatever reporting
method is used, the dataset has been developed by the NPSA to include
specific and targeted questions on medication errors. Pharmacists will
be asked whether the incident occurred at the prescription, preparation
or administration stage, and if the problem involved, for example, the
wrong patient, drug, dose or formulation and any details of associated
issues such as labelling and packaging.
As part of its commitment to maintaining the anonymity of staff and patients,
the NPSA will store all information from the NRLS anonymously and will
not investigate individual incidents. The system will retain the names
of NHS organisations that report directly however, and this will therefore
apply to hospital-based pharmacists reporting through their local NHS
system. This will enable the NPSA to offer those organisations feedback
on particular developments in reported incident rates.
Analysis of trends
The analysis of NRLS data will focus on the key themes and trends that
emerge, such as certain drugs, processes and procedures that occur
more frequently than others and how they shed light on systemic failures
in patient care. The information will then be fed back to the NPSA
safe medication practice team, who will identify cross-cutting issues
and inform the development and prioritisation of practical national
solutions.
The NPSA is still evaluating possible reporting routes for community
pharmacists and the exact procedures to be followed. It is currently
examining the options in a working group involving representatives from
all the pharmacy groups and organisations, as well as IT suppliers to
community pharmacies. The final decision will be dependent on both the
new pharmacy contract and on developments in IT in the community setting.
The NPSA is pleased to have been involved in the discussions between
the Pharmaceutical Services Negotiating Committee, the Department of
Health, and the NHS Confederation, which firmly established patient safety
incident reporting as part of the wider clinical governance agenda.
In their role of verifying patient prescriptions and reviewing doctors’ instructions
to patients, pharmacists have always been the traditional guardians of
patient safety in the field of medication. The NRLS must harness pharmacists’ expertise
and gather the high quality data they can provide to track incidents
and developments in medication error successfully.
Pharmacists, therefore, have a vital role to play in both reporting the
incidents that require the attention of the NPSA, and in helping it to
work on solutions. The NRLS data will help to inform the direction and
focus of future research in patient safety, and the NPSA remains committed
to involving the pharmacy profession in the issues it targets and the
solutions it develops. |
