Once the blame-free reporting system is in place, 'adverse patient incidents'will be a thing of the past.At least, That is the idea.Paul Stephenson takes a closer look The National Patient Safety Agency says there can be 'no guarantees' that cases like that of GP Dr Harold Shipman and the Bristol heart babies could be prevented if problems were picked up early. But it says the likelihood of such incidents can be 'greatly' reduced by a changing culture of clinical governance, and the new national incident reporting system.
The scale of the problem was made clear by the expert group on learning from errors and adverse events in the NHS, chaired by chief medical officer Professor Liam Donaldson. Its report, Organisation with a Memory, published last year, suggested that 'adverse events' occur in about 10 per cent of admissions - which is in excess of 850,000 cases a year.
Last week concerns were raised about the appointment of Professor Rory Shaw, director of Hammersmith Hospitals trust, to chair the agency.
Sources were unsure that his background - as medical director at Hammersmith at a time in which five medical inquiries were held into the trust's imaging directorate and breast-screening recall systems - equips him for his new task.
Professor Shaw insists otherwise. He says his time at Hammersmith is precisely what gives him the experience to lead work on improving information sharing and reporting systems.
The key task for the NPSA will be to implement a national reporting system. Most of the 25 pilot sites chosen to work through the practicalities of central reporting have a couple of years' experience of collating information.
The pilots have been working on additional aspects of reporting such as complaint reporting, and the ability of GPs to report adverse incidents, but they all say that what is crucial is that information can be provided without fear of reprisal as part of a blamefree culture, and that the information is acted on.
The intention is that, once the pilots have completed their work, the national reporting will start at the beginning of next year. The pilots are based in two regions: West Midlands and Northern and Yorkshire. There are limited sites in and around London and elsewhere.
Tees and North East Yorkshire trust head of patient liaison and communication Linda Spraggon says: 'We already have established adverse-event reporting. Between August and December we will be notifying the department of anything we would classify as an adverse incident.
'There is an incident report form which staff can complete, that is usually signed off by a ward manager or other manager and is sent up to the central trust riskmanagement department.
'We have been very, very keen to develop a no-blame culture.
Incidents may occur where action may need to be taken. Staff must feel that will only occur in extreme situations.'
At Dudley Group of Hospitals trust, the reporting system is set up so that once an incident is reported, the relevant people are alerted by e-mail. So, for example, if a needlestick injury is reported, occupational health would be contacted automatically.
As elsewhere, trust clinical governance co-ordinator Derek Eaves says: 'We try to adopt a blame-free culture.'
Pinderfields and Pontefract Hospitals trust finance director Mike Harrop, who heads risk reporting for the trust, says the no-blame culture 'has to work in practice. It is more about the values in the organisation.
'The national system goes a step further: there is a rigorous follow- up, where the requirement is to do a root-cause analysis. It is to take something that has happened or nearly gone wrong, and to go into what has happened, to look at the root causes and not the obvious.
'The obvious thing might be a consultant cutting off the wrong limb, but it might be that he has been up all night.
'The other thing we have tried to do is to take the system beyond the boundary of the hospital, and to take it into primary care. If GPs learn of a problem following discharge, they can report it.' He says there is no real system for reporting problems at present, and that the aim was for GPs to have a reporting book.
Barts and the London trust clinical governance unit manager Judy Chadwick says: 'I think the benefit of our system is that it has the ability to deal with complaints and claims as well.'
National reporting holds out the promise of avoiding future tragedies. The task now is to make sure this spreads across the NHS.
Key local requirements from the National Patient Safety Agency guidance Everyone involved in patient care is aware of what an adverse patient incident is.
The incident is reported to a designated person.
Information on all serious incidents is fast-tracked, where appropriate, to relevant external stakeholders.
All incidents are graded according to the impact on patients and the organisation.
Incidents are investigated and improvement strategies prepared if relevant.
'Red'incidents are reported to the NPSA within three working days, and to the regional office.
All red incidents have a full root-cause analysis by the local organisation to be reported to the NPSA and regional office within 45 working days.
Where appropriate, the organisation co-operates with the Department of Health to establish the need for an independent inquiry.
Aggregate reviews of incident information are undertaken regularly, and quarterly reports sent to the NPSA.
Lessons are learned from incidents, improvement strategies are implemented and monitored, and practice is changed where appropriate.