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BMJ 2002;324:1473 ( 22 June )

News

Patient safety agency admits problems with its pilot scheme

Alex Vass, BMJ

Preliminary figures from a pilot system for reporting adverse incidents in the NHS were released this week with a warning that the raw data were "unreliable and not sufficiently robust for a government publication."

Data collected by the National Patient Safety Agency show that more than 27000 adverse incidents have been reported over the past nine months, far fewer than expected from international studies on adverse incidents. However, there were substantial problems with the pilot.

Professor Liam Donaldson, chief medical officer for England, said: "Fifty to sixty per cent of the data collected by the agency was not classified due to problems with computers not talking to each other properly and an overcomplicated form for reporting."

The agency, however, did use the data to issue an alert on phials of potassium chloride. Thirty one incidents and three deaths were reported, and the agency recommended that it be removed from all wards where it was not strictly required. The agency said they would also be working with the manufacturers to work out a suitable range of diluted products, as well as possible changes to the packaging.

The agency was set up in July 2001 to identify and learn from adverse events and "near misses" occurring in the NHS. The feasibility of a national reporting system through which incidents are reported without apportioning blame, was piloted in 28 trusts across England and Wales over the past nine months. The aim is to roll out the system to all acute and mental health trusts by December 2002 and 60% of primary care trusts by March 2003.

The agency figures show that less than 1% of patients had an adverse incident. Professor Donaldson said that this percentage changed, however, if it were assumed that relatively few adverse reports came from the GP and mental health trusts and from ambulance services in the pilot because the culture of reporting was less developed in these sectors. When the reported incidents were taken to represent adverse incidents in acute trusts alone, the percentage was nearer 10% which "is broadly in line with international research studies."

Two per cent of the reported incidents were classed as "catastrophic" and 19% as minor, including such events as falls where no injury was sustained. Seventeen per cent were classed as non-clinical.

Susan Williams, joint chief executive of the agency, said the number of reports were "encouragingly higher" than she had expected from the trial of such a new system. However, she said that the pilot had thrown up a number of problems that needed to be solved before it could be rolled out to the whole NHS.

Improved information technology, a better designed form for recording incidents, and an improved grading system of adverse events were key areas identified as requiring urgent attention.

© BMJ 2002
 

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