The Pharmaceutical Journal
Vol 277 No 7409 p67
15 July 2006

This article
Reprint   Photocopy

  Acrobat Reader

News summary

MPs say NPSA has not improved safety enough

Insufficient progress has been made in improving safety in the NHS over the past few years, according to a new parliamentary report.

“A safer place for patients: learning to improve patient safety”, published by the House of Commons Select Committee on Public Accounts, says that, despite notable improvements in the development of a more open reporting culture in the NHS, under-reporting of safety incidents remains a problem.

The report says that some 974,000 patient safety incidents and near misses were recorded on NHS trusts’ reporting systems in 2004–05, but trusts estimate that on average 22 per cent of incidents and 39 per cent of near misses go unreported. Medication errors and incidents leading to serious harm are thought to be the least likely incidents to be reported.

The report questions the value for money of the National Patient Safety Agency. When the NPSA was established, it was allocated a budget of about £15m. By 2004–05 this had increased to £17m, and in 2005–06, following an increase in its remit, the budget was £35m. The report outlines progress made by the NPSA, including published guidance on good practice in dealing with staff involved in incidents, training 8,000 staff in an accident investigation technique, and issuing guidance to chief executives in their role in promoting safety.

However, it highlights delays in establishing the National Reporting and Learning System (NRLS) and its overrunning costs, and says that the NRLS has not helped simplify reporting incidents for trusts.

According to the report, trusts generally perceive that the NPSA has failed to maximise learning because it has not provided feedback of solutions quickly and regularly. Furthermore, the NPSA is criticised for failing to evaluate and promulgate solutions that have been developed at trust level. The report also states that trusts have not done enough to tell patients when things go wrong or to involve them in developing solutions to incidents.

Susan Williams, joint chief executive of the NPSA, said: “The NPSA welcomes this report. The committee of public accounts acknowledges that progress has been made and we agree that more needs to be achieved to secure even safer health care in the NHS.”

She said that the NPSA has already acted on a number of issues identified in the report and will work with the Department of Health to consider the report’s recommendations carefully.

“The Agency remains committed to helping improve patient safety in the NHS and working with the local NHS to deliver this,” she added. “A publications strategy has been agreed with the Department of Health and we plan to publish our second key report on safety incidents in the summer.”