NPSA to change its focus as part of new patient safety strategy
The DoH’s report |
Procedures designed to improve patient safety are to be overhauled next
year, including a redesign of the National Patient Safety Agency's National
Reporting and Learning System and of the NPSA itself. The recommendations
come in “Safety
first: a report for patients, clinicians and health care managers”,
published by the Department of Health last week as part of a renewed
national strategy for patient safety.
The report is the result of a review commissioned by the Chief Medical
Officer for England to address issues raised in the National Audit Office
report “A
safer place for patients: learning to improve patient safety” (PJ, 12 November 2005, p597) as well as to look at the
NHS approach to patient safety more widely.
The review found little evidence, despite the large volume of reports,
that the NRLS is delivering high-quality, routinely available information
on patterns, trends and underlying causes of harm to patients. It says
that the system must be re-engineered to make it more effective. Near
misses and a new category of “adverse events that could happen” should
be reported and reports should be simplified. To promote rapif and effective
learning, reports should be confidential but not anonymous. The new system
will be relaunched in 2007.
The report also recommends that the role of the NPSA should be refocused
on its core objective of collecting and analysing patient safety data
to inform rapid patient safety learning, priority setting and co-ordinated
activity across the NHS.
It advises that the NPSA should work in partnership with agencies that
gather data, such as complaints, claims and coroners’ reports,
to ensure that all deaths and serious harm associated with adverse events
are identified.
To allow this to happen, the report recommends that a number of the NPSA’s
current functions should be commissioned from other expert agencies.
These functions include patient involvement, awareness raising, technical
solution development and education. A pilot should be established to
examine whether the National Institute for Health and Clinical Excellence
could develop technical patient safety solutions.
Other recommendations
• All incident reports should be considered locally
within 24 hours and the NPSA should be notified of any incidents
involving serious
patient harm or death within 36 hours
• Patient safety action teams, accountable to strategic health
authorities, should work to support local NHS organisations
and would decide which
incidents should be investigated and at what level
• The NHS Institute for Innovation and Improvement should work
with the medical Royal colleges to develop a patient safety curriculum,
which should be widely implemented in undergraduate, postgraduate
and continuing education
• A National Patient Safety Forum should be established to bring
together key stakeholders and influence the development of the
patient safety agenda
• The NHS should take steps to ensure that patient safety is
embedded as a core principle that underpins the next round of
national priorities,
which will be established from 2008 |
|
The
Pharmaceutical Journal
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