Published as NHS QIS hosted a national conference on Clinical Governance and Patient Safety, the report, Safe Today Safer Tomorrow, examines the current systems, attitudes among staff to reporting incidents and near-misses, and the lessons that can be applied to local systems from existing national systems and experience elsewhere in the UK. It found:
- All NHS Boards collect information on incidents and near-misses. These systems have a number of limitations, however, including under-reporting, a lack of recording of human risk factors such as stress, and inadequate training.
- Staff perceptions are that a culture of blame still exists, particularly as reporting an incident often leads to disciplinary action. The response to error and incident reporting is seen as inconsistent, while feedback and remedial action is limited.
- A comparison between existing local systems and national reporting systems, for issues such as surgical deaths, suggests that differences in scope and scale make it impractical to import national approaches into local systems. Comparisons with systems south of the border suggest that problems in capturing the right data make implementation of a similar system impractical.
Commenting on the report, NHS QIS Director of Performance Assessment and Practice Development, Ms Jan Warner, said:
Everyone accepts that there will always be incidents where a patient s treatment goes wrong. The key is to learn from these incidents and minimise the chance of the incidents happening again.
Perhaps even more important is that we learn from those near-misses that almost lead to harm. If we can capture the lessons of near-misses we can minimise the harm to patients even further.
This review has confirmed that while there is much work underway, it needs to be more consistent and co-ordinated if NHSScotland is to learn from experience in future.
It also reveals that the health service still has yet to create a culture that encourages the reporting of incidents. This is a vital task. No matter how good the systems, if staff feel they cannot report an incident, then lessons will not be learned.
What has been hugely encouraging is the overwhelming support and enthusiasm we encountered in the NHS for the aims of this work. The health service is clearly committed to putting in place the right systems to protect patients. This is the foundation that we will now build upon as we develop new systems.
Note to Editors:
- An incident is defined as an unintended or unexpected event that led to patient or staff harm, including death, disability, injury, disease or suffering. A near-miss is any situation that could have resulted in an incident, but did not due to either chance or intervention.
- The report was published as NHS QIS hosted a national conference, Facing Challenges: Sharing Solutions, to provide an opportunity for NHSScotland staff at all levels to network, learn new concepts and share good practice and solutions in clinical governance, risk management and patient safety.
- NHS QIS has been established to lead in improving the quality of care and treatment delivered by NHSScotland. To do this it sets standards and monitors performance, and provides NHSScotland with advice, guidance and support on effective clinical practice and service improvements.
Media Contact: Colin McAllister on 07813 095930