Hospital Pharmacist
2005;12:293
September 2005

News summary

NPSA reports the first public analysis of patient safety data

The first report of patient safety incidents in England and Wales has been published by the National Patient Safety Agency (NPSA). It describes the Patient Safety Observatory and provides information on the National Reporting and Learning System (NRLS). The NRLS is the first comprehensive national reporting system for patient safety incidents and the only reporting system to cover all health care settings. The information in the report is based on data from the 230 organisations in England and Wales that had reported 85,342 incidents up to 31 March 2005.

The Patient Safety Observatory combined and compared data from the NRLS with other sources of information such as litigation bodies, industry and patients to provide a more complete picture of patient safety. These data were then used to identify trends and highlight priority areas for the NPSA to target.

Susan Williams, joint chief executive, NPSA said, “this is the first national system of its kind in the world” and “the report is a milestone for the NPSA, the NHS and the public”.

The majority of the data on patient safety incidents were obtained from local incident reporting systems from acute hospitals. The NPSA emphasised that high incident reporting rates may be a reflection of openness to reporting at a local level and does not mean that a given trust has more incidents than other trusts.

Most incidents reported resulted in no harm to the patient (68 per cent) and around 1 per cent resulted in severe harm or death. Patient accidents, incidents associated with treatments or procedures and medication incidents were most commonly reported with communication factors and lack of teamwork being cited as major contributing factors.

Several issues have been identified in this report: anticoagulant medication, patient identification and missing equipment from crash call trolleys. The NRLS database contained 311 incidents involving anticoagulants, including two deaths. Negligence claims showed 120 cases that resulted in death from incidents involving anticoagulants. The most frequent types of error relating to anticoagulants were overdose, poor record keeping, contraindications for use and problems with monitoring. This issue was identified as a priority by the NPSA for further work and solutions are being developed in collaboration with the British Society for Haematology.

Another issue highlighted was the number of incidents involving look-alike medicines. The NPSA is currently working with the Medicines and Healthcare Products Regulatory Agency to encourage the pharmaceutical industry to change packaging for different drugs and different strengths so that they are clearly distinguishable.

The report also found that the practical aspects of drug preparation and administration are not formally taught, with nurses generally learning from one another on the hospital wards. The report stated: “Medicines with confusing information about preparation and administration, and requiring complex calculation, preparation and administration methods are supplied with limited help and assistance for ward staff.”

The NPSA intends to encourage pharmacists’ involvement in the training in and audit of the preparation and administration of injectable medicines. It is currently working on this issue with a number of pharmacists and hopes to publish a report of its findings at the end of the year.