Jul 6 2006
According to a report on the National Health Service (NHS) in the UK, 1 in 10 patients admitted to NHS hospitals is unintentionally harmed and almost a million safety incidents, more than 2,000 of which were fatal, were recorded last year.
Edward Leigh, the chairman of the House of Commons Accounts Committee, says such figures were "terrifying enough", but the reality may be worse because of the "substantial under-reporting" of serious incidents and deaths in the NHS.
It seems the NHS has no idea how many people die each year as a result of medical error and a lack of accurate information on serious incidents and deaths makes it difficult for the NHS to evaluate risk or get a grip on reducing high risk incidents.
The committee found that some 974,000 patient safety incidents or "near misses", including 2,181 patient deaths, were recorded by the NHS but it says under-reporting is a serious problem and few hospitals routinely inform patients involved in a reported incident.
The report is highly critical of the government's National Patient Safety Agency established in 2001 to encourage the reporting of mistakes by healthcare staff, and says it's performance to date has been unimpressive.
In one year, NHS staff reported nearly a million incidents in which patients were harmed or where there was a near-miss but hospitals estimate that around 22% of errors, mainly involving people being given the wrong drug or wrong dose or incidents that have led to serious harm, are unreported.
Doctors it appears are less likely to report an incident than other staff groups and even though disciplinary action may be an appropriate response when patient safety is at risk, nursing and other non-medical staff fear that they risk suspicion if they report a serious incident.
It also appears that patient safety alerts and other solutions are not always complied with.
Leigh, says the findings point to two "deep-seated failures": that of the NHS to secure accurate information on safety incidents and the failure "on a staggering scale" to learn from experience.
Leigh says around 50 percent of all actual incidents might have been avoided if NHS staff had learnt lessons from previous ones.
The report believes it could take a decade or more to improve safety in the NHS but more immediate progress might be seen with the introduction of electronic patient records which should reduce accidents caused by misinterpretation of doctors' handwriting.