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Patient safety incidents rise 25% in primary care organisations

OnMedica staff

Wednesday, 7 October 2009

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Patient safety incidents reported have risen by 25% in primary care over a six month period compared with the previous half year, according to new figures published today by the National Patient Safety Agency (NPSA).

The sharp rise, however, is largely due to more reporting and less secretive culture in the NHS, said the Agency, which released its Organisational Patient Safety Incident Reports for each NHS trust or local health board across England and Wales.

The reports are designed for boards to use to compare their reporting profile with similar NHS organisations and set priorities for local action.

The reports detail incidents reported by frontline NHS staff that have occurred between October 2008 and March 2009, and reported to the NPSA by 30 June 2009.

More trusts are reporting more often, said the NPSA, and 98% of trusts across England provided incident reports to the NPSA – a 3% increase compared to the previous period. There was a 7% increase in the overall number of incidents reported. For primary care, there was a 25% increase.

The severity of these incidents was shown to be low as across England, 92.5% of all patient safety incidents resulted in low or no harm to the patient.

In addition, 6.2% of incidents were reported as moderate harm to patients, 0.8% as severe harm to patients and 0.4% as contributing to patient death.

Full summary reports are available for 382 out of the 392 trusts in England and 10 trusts across England did not submit any reports or did not submit enough reports to be eligible for inclusion. Of the ten trusts without full reports, six were PCTs, two are acute trusts, and two are mental health trusts.

The most commonly reported incident type overall was patient accident (32.8% of reports), followed by treatment/procedure (10.1%) and medication (9.4%).

The Agency works with doctors, nurses, pharmacists and safety experts to analyse the incident reports and identify common safety problems that need action across the NHS.

In the past six months, this has included new guidance on oxygen safety, the clinical use of suprapubic catheters, and how delayed appointments could lead to blindness amongst patients with glaucoma.

NPSA chief executive Martin Fletcher said: “National reporting and learning means that the lessons learnt from safety problems are not trapped within the walls of one facility but can be spread across the NHS to prevent similar events occurring.

“More reports do not mean more risks to patients. Indeed quite the reverse. These data are sound evidence of an improving reporting culture across the NHS. Frontline staff are more likely than ever to raise safety concerns much more openly.”

Cynthia Bower, chief executive of the Care Quality Commission, said: “Every NHS trust should be monitoring these data closely to identify patterns of poor care, spot potential problems early and to make services safer for patients.”

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