Patient safety incidents have been reported in the media over many years. The banner headlines describe the shocking events and a similar story unfolds soon afterwards. The frequency with which this happens has caused me to reflect on the risk that we could become desensitised and all too accustomed to such incidents occurring.
For the NHS, this could result in patient safety slipping in terms of policy development priority, with incidents ceasing to have the powerful effect they have today. NHS staff could start to switch off as they struggle to cope with increasing workloads. For the public, fatigue with the news could set in. Yet another NHS patient safety incident is reported: initial shock, shortly followed by another incident, with nothing seemingly changing to stop it happening. They could also lose confidence in the NHS. There is an urgent need to develop an ingrained patient safety culture in the NHS and reduce the level of incidents occurring.
There is evidence that some staff struggle to cope with the volume of patient safety guidance being issued, with little time and space to implement it (Care Quality Commission (CQC), 2018); NHS Improvement, 2019a).
Shocking incidents
Last month, there were two media reports on patient safety incidents:
‘The removal of a man's eye was avoidable after an infection was not spotted early enough, a watchdog found.’
And a news story about NHS ‘never events’ reported the case of a man who was circumcised by mistake:
‘A man was accidentally circumcised after a hospital mistakenly carried out the wrong procedure. The patient was supposed to have a cystoscopy … But surgeons instead removed his foreskin after mixing up his medical notes with another patient.
Continuing blitz of safety incidents
More shocking patient safety news stories can be easily found by reviewing the frequently issued reports of the Parliamentary and Health Service Ombudsman, NHS Improvement and the CQC. Reports into NHS patient safety incidents have been published for many years, with similar findings and headlines, but tragic errors persist. The NHS sadly never seems to learn from patient safety incidents of the past.
Making change happen
Powell and Walshe (2019) discussed 50 years of inquiries in the NHS and their purpose, values and outcomes. The key matter here is to make sure that government inquiry recommendations are followed up and positive changes result.
The Mid Staffordshire crisis shook the NHS down to its foundations. In terms of patient safety policy development, it led to positive developments in several areas, including how the CQC assesses quality and safety. Reports into major patient safety incidents promise change in the aftermath of tragic events, but endemic change is not always forthcoming. The NHS resolutely maintains a defensive stance on patient safety incidents. It is a long way from developing an ingrained patient safety culture that puts the patient first. The CQC recently made clarion call for a change in NHS culture:
‘Fundamentally, the safety culture of the NHS has to radically transform if we are to reduce the toll of never events and the much greater number of other safety events.’
Overwhelmed staff
There is a danger that the sheer number of patient safety incidents and their repercussions could overwhelm NHS staff. There is evidence (CQC, 2018) that staff are struggling to cope with the large amount of patient safety guidance being produced and that this is having a negative effect in reducing the incidence of never events:
‘Trusts receive too many safety-related messages from too many different sources. The trusts we spoke to said there needed to be better communication and coordination between national bodies, and greater clarity around the roles of the various organisations that send these messages.
The CQC (2018) identified competing pressures on staff due to high workloads. Implementing patient safety alerts can be viewed as just one more thing to do, which can lead to a mechanistic and siloed approach to implementation. The systems and processes are also not always helpful in allowing staff to deal properly with safety matters:
‘There is no clear system for staff to learn from each other at a national level. Local reporting systems are often poor quality and do not support staff well.’
NHS Improvement reports
NHS Improvement has just published its latest report on never events that occurred over 11 months up to February 2019 (NHS Improvement, 2019a), which makes for uncomfortable reading.
Reported never events
NHS Improvement (2019a) defines never events 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 that there were 451 never events between 1 April 2018 and 28 February 2019. These are provisional figures, and it is possible that further local investigation may result in changes to the categorisation.
These are some of the never events reported (NHS Improvement, 2019a: 6–7):
National patient safety incident reports commentary
Another NHS Improvement (2019b) report interprets the data in the national patient safety incident reports for England. The data and commentary are part of a range of official statistics on patient safety incidents reported to the National Reporting and Learning System (NRLS). The report contains a lot of technical information on data collection and outputs, but also important information on patient safety trends. Between July and September 2018, 488 242 incidents were reported to the NRLS. This is a 4.1% increase from the 485 156 reported between July and September 2017.
In terms of the top four incident categories, the report states that between October 2017 and September 2018 these were (NHS Improvement, 2019b: 10):
In England, the care settings where the reported incidents took place between October 2017 and September 2018 were (NHS Improvement, 2019b: 11):
Degree of harm: death, severe harm
The degree of harm caused is an important factor because it helps us focus on the incident and crystallises the urgency of the situation, so further investigation and review can take place.
NHS Improvement (2019b) states that the degree of harm should describe the actual extent of harm suffered by the patient as a direct result of an incident. There are five NRLS categories for degree of harm: no harm, low harm, moderate harm, severe harm, and death. The reports expand on this:
‘Severe harm—any unexpected or unintended incident that caused permanent or long-term harm to one or more persons Death—any unexpected or unintended event that caused the death of one or more persons.’
The report states that, nationally, most incidents are reported as causing no or low harm. Between October 2017 and September 2018, about 74.7% out of a total of 1 991 783 incidents (NHS Improvement, 2019b: 13) were reported as causing no harm and 22.1% low harm. The remainder were reported as causing moderate harm (2.6%), severe harm (0.3%) and death (0.2 %). It is reassuring to know that most incidents cause no or low harm, although it would be better if they had never occurred in the first place, but some degree of error is to be expected, given the nature of health care. As human beings practising nursing and medicine and working with patients in often complex care environments, we are all fallible and can and do make mistakes. The best we can do is to try to work effectively to minimise the risk of errors happening in the first place.
What is a stark finding, along with the degree of severe harm suffered, is the number of deaths. Whichever way we look at the statistics and the report, the 4717 deaths (0.2%) caused by reported patient safety incidents in England are significant and unacceptable. See NHS Improvement (2019b) for the sources to read a full breakdown of the data.
Conclusion
We are never going to eradicate error from health care because no one is infallible, and treating and caring for patients can be a complex process. The NHS can, however, do better in minimising the risk of never events and other patient safety errors occurring. Never events are by their nature headline grabbing and portray unforgivable errors. This can have the possible consequence of destroying public confidence in the NHS. In the public's mind, it can also create a sense of fatigue with errors seemingly happening all too frequently.
The impact of patient safety incidents on NHS staff should not be forgotten. Some staff struggle to keep up with the volume of patient safety guidance being produced. Patient safety is big business, with many stakeholders and agencies offering services and solutions. We must guard against ‘health carer switch-off’, as staff struggle to cope with increasing workloads and try to fit in new guidance in environments that may not be totally supportive (CQC, 2018).
NHS Improvement (2019b) starkly reveals that patient safety incidents are causing severe harm and deaths and this, to my mind, is unacceptable by any account.