Drug errors make up 7.1pc of safety incidents
Medication errors are the second biggest cause of known patient safety incidents in the NHS, according to a report published last week by the National Audit Office.
They are to blame for an estimated 7.1 per cent of patient safety incidents
reported by hospital, mental health and ambulance trusts in 2004, says
the report, “A safer place for patients: learning to improve patient
safety” (PDF 1.4 MB).
The most common cause for incident reporting, however, was patient injury
due to falls, which accounted for 32.5 per cent of cases.
But the NAO believes that a significant number of incidents still go
unreported, particularly cases involving medicine errors or those “leading
to serious harm”. The continued presence of a blame culture in
trusts is one of the main reasons why staff are still reluctant to report
patient safety incidents, the report says.
The NAO wants to see patient safety issues included in all professional
clinical training, both pre- and post-registration, to help staff accept
they have a responsibility for patient safety and to try to break down
the blame culture.
The role of the National Clinical Assessment
Authority (NCAA), whose
remit is to support poor performing doctors and dentists, should also
be extended to apply to other clinicians, the report recommends.
Tony West, president of the Guild of Healthcare Pharmacists, commented
that it is particularly difficult to change the culture of an organisation
when there is a litigious system which can end in court.
He said the recommendation to increase the remit of the NCAA to other
health professionals threw a question mark over the role of the existing
regulators and employers which have a responsibility and a duty to deal
with poor performing professionals.
He commented: “I think we would need to know how successful the
NCAA has been with doctors and dentists before deciding to roll it out
to other health professionals.”
Learning lessons
The NAO report estimates that half of the incidents in which patients
are harmed could have been avoided if lessons had been learnt from
previous cases.
Although reporting of incidents at a local level had improved there
had been a two-year delay in rolling out the national reporting
system developed by the National Patient Safety Agency. By August
this year at least 35 trusts had still not returned any data to
the national reporting system.
The NAO says that there has been a year-on-year increase in the
number of reported patient safety incidents with 980,000 reports
during 2004-05. Of those, 2,081 resulted in deaths.
But the NAO acknowledges that the true number of deaths may be
significantly higher because of the under-reporting of incidents.
Sir John Bourn, comptroller and auditor general at the NAO, said: “There
needs to be significantly faster progress at the national level
in ensuring effective evaluation of numbers, types and causes of
incidents. And lessons and solutions must be better evaluated and
shared by all organisations with a role in keeping patients safe.” |
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