Thousands of NHS patients suffer avoidable medical errors, says Healthcare Commission

Thousands of patients are the victims of medical errors that could have been avoided if safety was given a higher priority in the NHS, the health watchdog has warned. Incidents where patients were harmed or so called near-misses are not being reported meaning lessons cannot be learned and future problems avoided, the Healthcare Commission said in its annual State of Healthcare report. One in ten patients admitted to hospitals will suffer from an error and around half of these could have been avoided, it warns.

The report said only half of NHS trusts comply with all safety standards and there has been little improvement. Errors that have led to patients being harmed include incorrect diagnosis, wrong doses of medication, surgeons operating on the wrong part of the body and paperwork going missing.

The wide ranging report covers all aspects of healthcare in England and highlights a number of areas of significant improvement in the NHS, particularly around deaths from cancer and heart disease and huge reductions in waiting times.

Demand for healthcare has increased dramatically, the NHS has higher levels of funding than ever before, and the health of the nation is improving, the report said. However, the last annual report before the Healthcare Commission is subsumed by the Care Quality Commission, the report focuses on patient safety and the lack of progress in the last five years. The report said too few incidents are reported to the National Patient Safety Agency with particular problems in primary care where doctors and nurses report almost no errors although the majority of patient care is delivered by GPs.

The report said there are 'up to 600 errors a day in primary care' but this was disputed by the Department of Health and the British Medical Association as based on research in other countries. The NPSA received 959,000 incidents of errors in 2007/8 but "worryingly" the report said seven per cent of hospital trusts and 13 per cent of primary care trusts did not report any incidents.

Prof Sir Ian Kennedy, chairman of the Healthcare Commission, said: "In my view the NHS is really only just out of the starting blocks. "There is a lot more we can do before we can be confident that the care patients receive is as safe as it reasonably can be. "What must change and change quickly is that we don't know very much about how safe care is in primary care. Information about missed diagnoses and late diagnoses won't show up on anyone's register of incidents of untoward events. "Safe care is what patients expect and what they are entitled to. "The real responsibility for the safety of care lies with those who provide care locally, namely the trusts and the boards responsible for trusts." He said unless safety is "internalised in their DNA" then nothing can change.

The Healthcare Commission called for one national database of serious incidents as the recording of errors is currently spread across different organisations. And hospital trusts and primary care trusts should also be measured on their serious untoward incidents and how they learn from them.

Dr Hamish Meldrum, Chairman of Council at the British Medical Association said: "The overall picture in this report is of major improvements to standards of care. We applaud the efforts of NHS staff in reducing the amount of time patients have to wait, and improving the quality of the care they receive. "Any errors are regrettable but there are millions of contacts between the NHS and patients every day. It is inevitable that, in a very small proportion of these, care falls below the highest standards. Doctors want to get rid of unacceptable variations in quality, but we need to be careful to analyse and learn from the causes of low performance rather than jumping to conclusions or simply adopting a blame culture."

Martin Fletcher, Chief Executive at the National Patient Safety Agency, said: "Good reporting is the cornerstone of patient safety. Safety cannot be improved without a range of valid reporting, analytical and investigative tools that identify the sources and causes of risk in a way that leads to preventative action. The National Reporting and Learning System has a vital role to play in supporting NHS organisations to identify risks to safe patient care. Patient safety needs to be everyone's responsibility."

Health Minister Lord Darzi said: "The NHS sees a million people every 36 hours. Unfortunately, as in any modern health service, mistakes and unforeseen incidents will happen. Only a very small number of errors put patients at serious risk. "We know there's more work to be done and are leading the way worldwide, having set up the National Patient Safety Agency and established a reporting and learning system to encourage open reporting. The introduction of quality quality accounts will refocus the attention of the boards of NHS bodies on the quality and safety."

Source