The National Patient Safety Agency (NPSA) was a Special Health Authority created to co-ordinate the efforts of all those involved in healthcare, and more importantly to learn from, adverse incidents occurring in the NHS.
As well as making sure that incidents were reported in the first place, the NPSA aimed to promote an open and fair culture in hospitals and across the health service, encouraging doctors and other staff to report incidents and “near misses”, when things almost go wrong. A key aim was to encourage staff to report incidents without fear of personal reprimand and know that by sharing their experiences others will be able to learn lessons and improve patient safety. The change of emphasis was more about the “how” than the “who”.
The NPSA collected reports from across the country and initiated preventative measures, so that the whole country could learn from each case, and patient safety throughout the NHS would be improved every time.
The NPSA played a key role in bringing patient safety to a national level, enabling the entire NHS to learn from incidents and make itself safer and more stress free for patients.
Why have an organisation with a responsibility for patient safety?
With an estimated 850,000 incidents and errors occurring every year in the NHS, reducing medical errors and improving patient safety are critical issues in healthcare today. The costs in human tragedy and suffering to patients, with a third of adverse incidents leading to disability or death; the effects on healthcare staff involved; and the financial costs mean there has never been a greater need to improve patient safety and the patient environment.
In June 2000, the Government accepted all recommendations made in the report of an expert group, led by Dr Liam Donaldson, Chief Medical Officer, called An Organisation with a Memory. The report acknowledged that there has been little systematic learning from adverse events and service failure in the NHS in the past and drew attention to the scale of the problem of potentially avoidable events that result in unintended harm to patients.
An Organisation with a Memory proposed solutions based on developing a culture of openness, reporting and safety consciousness within NHS organisations. It proposed the introduction of a new national system for identifying adverse events and near misses in healthcare to gather information on causes and to learn and act to reduce risk and prevent similar events occurring in future.
How did the NPSA improve patient safety?
- by collecting and analysing information on adverse incidents from local NHS organisations, NHS staff, patients and carers
- by taking into account other safety-related information from a variety of existing reporting systems
- by learning lessons and ensuring that they were fed back into health care and treatment is organised and delivered
- by ensuring that where risks were identified, work is undertaken on producing solutions to prevent harm, specify national goals and establish mechanisms to track progress
- Through its work and the new national reporting system, the NPSA worked towards the achievement of targets around specific risks and aim to:
- reduced to zero the number of patients dying or being paralysed by maladministered spinal injections
- reduced by 25% the number of instances of harm in the field of obstetrics and gynaecology which result in litigation
- reduced by 40% the number of serious errors in the use of prescribed drugs
- reduced to zero the number of suicides by mental health patients as a result of hanging from non-collapsible bed or shower curtain rails on ward