UK patient safety is improving
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《英国医生杂志》
Patient safety in the NHS has improved, but problems remain in areas such as the under-reporting of deaths and serious incidents caused by errors, the National Audit Office reported last week.
The study, based on surveys of NHS trusts, also found that not enough was being done to share lessons and solutions that had been learnt from previous adverse events. As many as half of the incidents in which NHS patients are unintentionally harmed could be avoided if lessons were properly shared, the watchdog concluded.
Previous studies have shown that about 10% of patients have an adverse event. Of these, about 60% are judged to cause low or no harm.
A Safer Place for Patients reports on findings from 256 NHS acute, ambulance, and mental health trusts. The National Audit Office found a year on year increase in incidents related to patient safety—a trend it put down to the drive to encourage staff to report adverse events.
According to the surveys, patients reported about 980 000 incidents and near misses in 2004-5. The estimated cost to the NHS of these incidents is some ￡2bn ($3.5bn; 3bn) a year. Falls and injuries were the most common incidents to be reported. But staff see this as having no direct link to the quality of care provided, the National Audit Office said.
But under-reporting was still significant for deaths and serious incidents—events that staff were more concerned to report. The office estimated that 22% of incidents went unreported—mainly medication errors and incidents leading to serious harm.
The watchdog estimated that 2181 deaths were recorded as a result of safety incidents in 2004-5. This is significantly higher than the National Patient Safety Agency's estimate of 840 deaths for the same year.
There had been improvements in encouraging doctors to report adverse incidents. This group is seen as most likely to overlook the need to do so. Some trusts had, as part of their performance management regimes, introduced a review of doctors' attitudes towards patient safety and evidence of reporting adverse events.
Other findings include:
Progress in reducing the blame culture, although the office's survey heard complaints from nurses and other non-medical staff that it still predominates in some trusts
Poor communication with patients still occured. Six per cent of trusts did not inform patients that they had been involved in a reported incident.(Rebecca Coombes)
The study, based on surveys of NHS trusts, also found that not enough was being done to share lessons and solutions that had been learnt from previous adverse events. As many as half of the incidents in which NHS patients are unintentionally harmed could be avoided if lessons were properly shared, the watchdog concluded.
Previous studies have shown that about 10% of patients have an adverse event. Of these, about 60% are judged to cause low or no harm.
A Safer Place for Patients reports on findings from 256 NHS acute, ambulance, and mental health trusts. The National Audit Office found a year on year increase in incidents related to patient safety—a trend it put down to the drive to encourage staff to report adverse events.
According to the surveys, patients reported about 980 000 incidents and near misses in 2004-5. The estimated cost to the NHS of these incidents is some ￡2bn ($3.5bn; 3bn) a year. Falls and injuries were the most common incidents to be reported. But staff see this as having no direct link to the quality of care provided, the National Audit Office said.
But under-reporting was still significant for deaths and serious incidents—events that staff were more concerned to report. The office estimated that 22% of incidents went unreported—mainly medication errors and incidents leading to serious harm.
The watchdog estimated that 2181 deaths were recorded as a result of safety incidents in 2004-5. This is significantly higher than the National Patient Safety Agency's estimate of 840 deaths for the same year.
There had been improvements in encouraging doctors to report adverse incidents. This group is seen as most likely to overlook the need to do so. Some trusts had, as part of their performance management regimes, introduced a review of doctors' attitudes towards patient safety and evidence of reporting adverse events.
Other findings include:
Progress in reducing the blame culture, although the office's survey heard complaints from nurses and other non-medical staff that it still predominates in some trusts
Poor communication with patients still occured. Six per cent of trusts did not inform patients that they had been involved in a reported incident.(Rebecca Coombes)