Reviewing and Responding to Patient Safety Incidents in the NHS

NHS Improvement, which supports the NHS (National Health Service) and helps improve care for patients, have just published their latest report on Never Events occurring between April 1, 2018 and February 28 2019.

The report makes for uncomfortable reading, as Never Events are not reducing.

Reported Never Events

Never Events are defined in the report as serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. The report shows 451 Never Events taking place between 1 April 2018 to 28th February 2019. The following are some of the Never Events reported:

  • Wrong site surgery: 182 events.
  • Adenoids removed in error during a tonsillectomy when plan was to conserve them: 1
  • Biopsy of wrong breast: 1
  • Botox injection instead of nerve block: 1
  • Cervical biopsy rather than biopsy of colon: 1
  • Circumcision rather than a flexible cystoscopy: 1
  • Cystoscopy undertaken that was intended for another patient: 1
  • Gastroscopy and colonoscopy intended for another patient: 1
  • Incision to wrong part of ear: 1
  • Grommet inserted to wrong ear: 1
  • Laser surgery to wrong eye: 1
  • Hysterectomy and salpingo-oophorectomy when the plan was to conserve one or both ovaries: 5
  • Tonsillectomy performed when not consented for: 2. (pp 6-7).
  • Retained foreign object post procedure events numbered 101 and included: Plastic tubing 1, Screw caps 1, Specimen retrieval bag 2, Surgical drain 1, Surgical forceps 1, Surgical needle 2, Surgical swab 11, Throat pack 2, Tonsil swab 1. (p10).

Sixty wrong implant or prosthesis are reported, and several other Never Events are detailed in the report.

National Reporting and Learning System (NRLS) national patient safety incident reports commentary

NHS Improvement have also recently published a report which interprets the data in the national patient safety incident reports (NaPSIR) for England.

The data and the commentary are part of a range of official statistics on patient safety incidents reported to the NRLS.The report contains a lot of technical information on data collection, outputs but there is also important information on patient safety trends. From July to September 2018, 488,242 incidents were reported to the NRLS from England. This represents a 4.1 percent increase on the number reported from July to September 2017 (485,156).

Degree of harm: Death and Severe Harm

The degree of harm caused is a vitally important factor as it helps us focus on the incident and crystallizes the urgency of the situation so that further investigation and review can take place.

There are five NRLS categories for the degree of harm: no harm, low harm, moderate harm, severe harm, and death. These categories are expanded on in the report, which states that nationally, most incidents are reported as causing no or low harm. From October 2017 to September 2018, approximately three-quarters of incidents were reported as causing no harm (74.7 percent or 1,487,988 incidents) and 22.1 percent (440,836 incidents) as causing low harm. The remaining incidents were reported as causing moderate harm (2.6 percent or 52,716 incidents), severe harm (0.3 percent or 5,526) and death (0.2 percent or 4,717 incidents). The total number of incidents was 1,991,783. (p13.)

What is a very stark finding, along with the degree of severe harm suffered, is that 4,717 deaths resulted. However, we look at the statistics and the report, 4,717 deaths caused by reported patient safety incidents in England is by itself a significant and unacceptable number.

Both reports contain very useful data on patient error which can help inform safety policy at national and local levels. A key to reducing patient error, Never Events in the NHS is to develop and ingrained patient safety culture which is proving hard to do.

Progress has been made but many challenges remain.



John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

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