Experts attack plans for mandatory error reports

Most NHS organisations already report such incidents to the National Patient Safety Agency voluntarily but from April 2010 it will be mandatory.

We have this obsession with incident reporting. Often people don’t realise they’ve made an error and it isn’t until much later we pick it up through a case note review

The change, outlined in draft regulations laid before Parliament, means organisations that do not report errors risk being fined, prosecuted or closed by the Care Quality Commission.

Critics have called the move “overly punitive”, arguing it will not improve patient safety.

It has added to mounting concerns that a series of hospital scandals and next year’s general election are intensifying political pressure for a more heavy handed regime for trusts.

US Institute for Healthcare Improvement president Don Berwick told HSJ: “Mandatory reporting is almost an oxymoron. People might not notice the injury or might not regard it as an accident. It’s illusory to say there will be a legal requirement [to report].”

But for the most serious incidents, such as maternal deaths, reporting was essential, he said.

The changes come into effect from 1 April, when organisations have to register with the CQC. A new protocol is being developed to encourage better information sharing between the NPSA and the watchdog.

Luton and Dunstable chief executive Stephen Ramsden, who chairs the national Patient Safety First campaign’s core team, said mandatory reporting would not improve safety.

He said: “We have this obsession with incident reporting. Often people don’t realise they’ve made an error and it isn’t until much later we pick it up through a case note review. We’re in danger of making it a more punitive culture with these increases in regulation that [follow] disasters and failures.”

He questioned whether the “election build-up” and “adverse publicity” generated by failures at Basildon and Thurrock University Hospitals Foundation Trust might lead to a more burdensome regulation regime.

NHS Confederation head of policy Nigel Edwards said voluntary reporting had removed the unhelpful blame culture.

However, CQC chief executive Cynthia Bower welcomed the move as “really good news for patients”. She added: “Healthcare can be risky and things will go wrong so we must be careful and sensitive in our approach.”

But Action Against Medical Accidents chief executive Peter Walsh said it was “unacceptable” there would be no duty on trusts to inform patients about incidents.