National reporting system for medical errors is launched
http://www.100md.com
《英国医生杂志》
BMJ
The world's first national system for collecting reports of health system failures and any error that compromises patients' safety was launched this week.
The national reporting and learning system (NRLS), which aims to improve patients' safety by collecting reports from health professionals across England and Wales, has been developed by the National Patient Safety Agency (NPSA), an organisation established in 2001 to tackle the problem of errors in the NHS.
The system will mostly extract information from existing local risk management systems. However, NHS health professionals will be able to report directly to the system through an online form if no local risk management system exists or if they prefer to do it that way. The system will retain information only in an anonymous form, and individual staff or patients involved in any incident will not be identified, says the agency.
The health minister Norman Warner launched the initiative at the agency's conference in Birmingham this week. He said: "It is essential that such incidents are reported locally, investigated, and analysed so that suitable learning and actions can follow. At the national level the NRLS will enable the NPSA to take an unprecedented overview, identify recurring patterns, and then develop practical solutions that can be applied consistently at the local level."
Susan Williams, who with Sue Osborn is joint chief executive of the agency, said: "Every day more than a million people are treated safely in the NHS. However, evidence tells us that in complex healthcare systems some things will go wrong. Research has also shown that errors fall into recurrent patterns regardless of the people involved.
Susan Williams: "As reporting levels rise the number of serious errors begins to decline"
"In developing the NRLS we have drawn from the experience of other sectors, such as the aviation industry, which shows clearly that as reporting levels rise the number of serious errors begins to decline."
The agency is planning to publish statistics on trends and issues that are identified through the system to promote a "learning culture" in the NHS. Ms Williams said: "Based on our consultations, health trusts and hospitals are quite keen on receiving comparative information to help them improve.
"We would not publish ratings of hospitals or trusts. However, we're working with the new Commission for Healthcare Audit and Inspection to help them make a judgment about how hospitals and trusts are doing with regard to patient safety.
"Although it seems counterintuitive, what we want to see is an increasing awareness of safety issues so that the number of reports increase but the incidence of serious harm goes down. In that sense we're hoping to mirror the experience of many other industries that we've looked at, including the aviation, railway, maritime, and nuclear industries."
The system was initially piloted in 28 trusts across England and Wales in 2001. After substantial problems with the pilot ( BMJ 2002;324: 1473) the system was further tested in 39 trusts.
The system is expected to cost about ￡1m ($1.9m; 1.5m) a year for the first eight years. "But we're not expecting it to cost as much as that in the later years," Ms Williams added.(Vittal Katikireddi)
The world's first national system for collecting reports of health system failures and any error that compromises patients' safety was launched this week.
The national reporting and learning system (NRLS), which aims to improve patients' safety by collecting reports from health professionals across England and Wales, has been developed by the National Patient Safety Agency (NPSA), an organisation established in 2001 to tackle the problem of errors in the NHS.
The system will mostly extract information from existing local risk management systems. However, NHS health professionals will be able to report directly to the system through an online form if no local risk management system exists or if they prefer to do it that way. The system will retain information only in an anonymous form, and individual staff or patients involved in any incident will not be identified, says the agency.
The health minister Norman Warner launched the initiative at the agency's conference in Birmingham this week. He said: "It is essential that such incidents are reported locally, investigated, and analysed so that suitable learning and actions can follow. At the national level the NRLS will enable the NPSA to take an unprecedented overview, identify recurring patterns, and then develop practical solutions that can be applied consistently at the local level."
Susan Williams, who with Sue Osborn is joint chief executive of the agency, said: "Every day more than a million people are treated safely in the NHS. However, evidence tells us that in complex healthcare systems some things will go wrong. Research has also shown that errors fall into recurrent patterns regardless of the people involved.
Susan Williams: "As reporting levels rise the number of serious errors begins to decline"
"In developing the NRLS we have drawn from the experience of other sectors, such as the aviation industry, which shows clearly that as reporting levels rise the number of serious errors begins to decline."
The agency is planning to publish statistics on trends and issues that are identified through the system to promote a "learning culture" in the NHS. Ms Williams said: "Based on our consultations, health trusts and hospitals are quite keen on receiving comparative information to help them improve.
"We would not publish ratings of hospitals or trusts. However, we're working with the new Commission for Healthcare Audit and Inspection to help them make a judgment about how hospitals and trusts are doing with regard to patient safety.
"Although it seems counterintuitive, what we want to see is an increasing awareness of safety issues so that the number of reports increase but the incidence of serious harm goes down. In that sense we're hoping to mirror the experience of many other industries that we've looked at, including the aviation, railway, maritime, and nuclear industries."
The system was initially piloted in 28 trusts across England and Wales in 2001. After substantial problems with the pilot ( BMJ 2002;324: 1473) the system was further tested in 39 trusts.
The system is expected to cost about ￡1m ($1.9m; 1.5m) a year for the first eight years. "But we're not expecting it to cost as much as that in the later years," Ms Williams added.(Vittal Katikireddi)