One million patients victims of NHS blunders

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http://www.dailymail.co.uk/pages/live/articles/news/news.html?in_article_id=394238&in_page_id=1770&ct=5

One million patients victims of NHS blunders
By JENNY HOPE, Daily Mail

01:00am 6th July 2006

The number could be halved if the Health Service took on board lessons
from previous accidents and acted promptly on safety alerts, it says.

Massive under-reporting of deaths and serious incidents means the NHS
'simply has no idea' how many people are dying each year, says the
influential Commons Public Accounts Committee (PAC).

It estimates there could be almost one-quarter of a million more
incidents - some of them serious - that go unreported each year, based
on evidence from trusts.

Big differences between similarly-sized trusts in the number of
incidents - from a few to many thousands - suggest some may be
discouraging such reports.

PAC chairman Edward Leigh said official estimates show one in 10
patients admitted to NHS hospitals is unintentionally harmed and there
has been insufficient progress in cutting the level of avoidable
incidents.

Mr Leigh attacked the "dysfunctional performance" of National Patient
Safety Agency - which costs £34 million a year to run - for delivering
a national reporting system "several years late" and poor value for
money for the taxpayer.

He strongly criticised trusts for failing to tell patients when things
go wrong - only one in four routinely keeps patients informed.

There were 940,000 reports of incidents and near-misses last year,
which include blunders ranging from medication errors and drug
interactions to missing emergency equipment and the wrong limbs being
amputated.

Mr Leigh said: "These statistics would be terrifying enough without
our learning that there is undoubtedly substantial under-reporting of
serious incidents and deaths.

"To top it all, the NHS simply has no idea how many people die each
year from patient safety incidents."

He said the NHS was failing on a "staggering scale" to learn from
previous experience.

"Around 50 per cent of all actual incidents might have been avoided if
NHS staff had learned lessons from previous ones" he said.

'Urgency'

Peter Walsh, chief executive of the charity Action against Medical
Accidents (AvMA), said it wanted an "injection of urgency" to improve
patient safety.

He said even more patients were at risk than the report allowed for,
as it did not include 300,000 reports of hospital-acquired infections
each year including the superbug MRSA.

He said "People have not woken up to the problem. Although the reports
include near misses, they stil have the potential to damage patients.

"The scary thing is we cannot have any degree of confidence that
things are getting any better. We want to see more teeth given to
existing guidelines and safety alerts - it should be compulsory for
NHS providers to implement them.

"It will come as a shock to many that some safety alerts are more or
less ignored by NHS trusts, and there is patchy compliance with
guidance on reporting incidents and being open with patients when
things go wrong."

A drive to improve patient safety began in 2000 when the Government's
Chief Medical Officer issued a report saying one in 10 hospital
patients was unintentionally harmed each year, costing the NHS
£2billion in extra bed days and £400million in settled clinical
negligence claims.

The PAC said there was a question mark over value for money from the
National Patient Safety Agency.

It had gone at least £1 billion over budget in setting up a reporting
system and was giving only limited feedback of solutions to trusts to
cut serious incidents.

Safety alerts issued to trusts were not always complied with - though
trusts claim they are, said the PAC.

Liberal Democrat health spokesman Steve Webb said: "In an organisation
the size of the NHS, mistakes are bound to happen, but the key issue
is whether lessons are learned. This was the whole point of the
National Patient Safety Agency.

"Endless delays by the Government in setting up the safety information
database have put patient safety at risk.

"The Government must ensure that safety information and best practice
is shared throughout the NHS far more efficiently."

Dr Gill Morgan, chief executive of the NHS Confederation, said the
report acknowledged progress "but quite rightly concludes that there
is still further work to be done in this area".

She added: "It is still relatively early days in the new system for
reporting incidents that affect patient safety. As the system becomes
more routine and more incidents are reported, we would expect the
headline figures of patient safety incidents to increase.

NPSA Joint Chief Executive Susan Williams said "We have launched and
connected every Trust in England and Wales to our national incident
reporting system - the first of its kind in health worldwide - and are
now receiving up to 55,000 reports every month.

"We have issued 16 safety solutions in the form of alerts as well as a
range of advisory reports to promote safer care for patients.
Implementing just two of our safety alerts should save the NHS at
least £52 million – a significant proportion of the total investment
in the NPSA."

Health Minister Andy Burnham said "Improving patient safety has been a
fundamental priority running through our policies to improve the
quality of NHS care.

"In the context where each month the NHS delivers 22.7million
treatments across hospital, community and primary care, it is
important to remember that the vast majority of NHS patients receive
safe and effective care.

"Only a small number of errors will have serious consequences.
However, as in any modern and increasingly complex health service,
mistakes and unforseen incidents can and will happen.

"Any mistake is one too many but we should remember that similar rates
of patient safety incidents occur worldwide."

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