Why hospital is a dangerous place to be

Almost 4,000 NHS patients in England died last year following “safety incidents”, in which some aspect of their care went wrong.

A further 7,500 patients suffered severe harm as a result of accidents or botched medical treatment.

Figures for the final six months of 2008-9, published yesterday by the National Patient Safety Agency, show that over the year 11,504 patients died or suffered severe harm as a result of medical errors, a rate of almost 1,000 a month.

Patients seeking medical attention accept that they are at risk from illness but do not expect to suffer as a result of bungled care. Yet NHS trusts still vary widely in the enthusiasm with which they monitor and report accidents, with a more than five fold variation in the number of incidents recorded by comparable NHS trusts.

The trusts with the highest level of incidents tend, paradoxically, to be the safest, because they have established an open culture in which accidents can be reported and learnt from. The NPSA has been struggling to persuade the NHS to behave more like the aviation industry which has a long established tradition in which pilots report every incident where something went wrong, however minor, and which has an excellent safety record as a result.

Overall, NHS trusts in England and Wales reported 924,748 incidents in 2008-9 of which more than 90 per cent caused little or no harm.

The most common were accidents in which the patient slipped or fell. One in ten involved errors in treatment including surgery or performing a procedure such as inserting a catheter.

A further one in ten were mistakes in which the wrong drug was given or the wrong dose.

Earlier this year the NPSA published the first safety reports for each trust. Martin Fletcher, chief executive, said: “We believe that trusts that have a high number of incident reports are likely to have a stronger safety culture. We individually review every incident that results in death or severe harm with the trust concerned. There may be a question of whether the incident was avoidable but if there are safety failings they should be addressed and we are particularly concerned to learn issues common across the NHS.”

“More trusts are reporting incidents more often. Frontline staff are more likely than ever to raise safety concerns. NHS trust boards need to use the information to review local approaches to patient safety. Only with strong leadership will we succeeed in making patient care even safer.”

Examples where the agency has intervened following deaths and serious injury, include new guidance issued last June on the use of oxygen, to avoid errors in which the wrong gas has been given to patients. There were 281 incidents in the last five years in which “poor management of oxygen” caused nine deaths and may have contributed to another 35 deaths.

Simple administrative errors resulted in 13 people going blind in one or both eyes and a further 44 suffering partial loss of sight. They were among 135 patients with glaucoma, in which the pressure in the eye rises potentially causing injury, whose follow up appointments were wrongly cancelled or delayed. Last May the agency urged NHS trusts to review their appointment systems.

Peter Walsh, chief executive of Action Against Medical Accidents, a campaign group, said reporting of incidents such as drug errors by GPs, where the bulk of patients are treated, remained “negligible.”

“We are calling for the reporting of patient safety incidents to be made legally mandatory in the new Care Quality Commission regulations being considered by Parliament this autumn. It follows that it should also be a legal requirement to report full circumstances of incidents resulting in harm to the patient or their next of kin. Not to do so would be a travesty”.