The Department of Health has announced the creation of an independent body to run a national database logging all 'failures, mistakes, errors and near misses' in the delivery of NHS healthcare.
The National Patient Safety Agency will go live as a special health authority on 1 July.
Recruitment for a chief executive and chair will begin now, with a full complement of staff due to be in place by the end of the year.
But the DoH was unable to say how many staff that would mean, nor what the cost of the new body would be. A spokesperson said: 'In the long term, ideally, the system will pay for itself, in terms of bringing down the costs to the NHS of clinical negligence and so on. '
The announcement came as chief medical officer Professor Liam Donaldson published the report of his expert group on learning from adverse events. An Organisation With a Memory - which updates a report from the expert group in June 2000 - demands improvements in the way adverse incidents are defined, as well as handled. It notes that, 'somewhat surprisingly', formal DoH guidance on untoward incident reporting issued in 1955 remains current.
'There is no standardised, operational definition of 'adverse incident' which would be easily understood by all NHS staff. '
It also highlights 'major differences' in the way data is handled by different regional offices, flagging up the good practice at Northern and Yorkshire region, which set up a standardised reporting system in 1995.
'Although the great majority of NHS trusts have some form of incident-reporting system in place, there is substantial variation in the coverage and sophistication of these systems, ' the report found. It quotes a 1999 report which suggested that one-fifth of trusts do not have reporting systems in place.
The DoH said the agency would 'work very closely' with both the Commission for Health Improvement and the Clinical Governance Support Team, but was unable to provide details of how they would work together.
An Organisation With A Memory. Report of an expert group on learning from adverse events in the NHS.
www. doh. gov. uk