Patient safety survey: those in peril

Patient safety has never been as high a priority for the NHS as it is now. But national monitoring processes are not picking up safety failures and incidents routinely go unreported, NHS professionals have told an HSJ poll. A patient falling from a window is just one of the incidents that staff said had gone unreported in their trust over the past year. Others ranged from "preventable post-surgical deaths" to "misidentification of a patient".

One respondent wrote of a "failure to recognise critically ill patients before it was too late, on multiple occasions", suggesting this is not just about one-off, isolated cases. Other examples involved outbreaks of healthcare acquired infections other than MRSA and C difficile, as well as prescribing errors.

In total, a quarter of the 168 people surveyed said they were aware of a patient safety incident occurring at their trust over the past year that had not been reported. Many respondents felt national monitoring processes, such as the reporting system run by the National Patient Safety Agency, were failing to pick up problems.

Overall, 71 per cent of those surveyed, who included middle managers, chief executives and doctors, agreed that national monitoring processes in patient safety were "weak". Of those, more than a third strongly agreed.

NPSA chief executive Martin Fletcher believes the big challenge in improving the quality of monitoring data is to ensure people actually see the benefits of reporting incidents. "People want to see that their concerns are being taken on board," he says.

The advantage of a national reporting system is that it means problems found in one or two trusts can be flagged up to similar organisations, he explains. The agency is trying to get this type of information out to trusts more quickly so that instant changes can be made locally.

The Patient Safety Campaign, due to launch in July, will focus on making sure good practices are used consistently, although Mr Fletcher recognises some trusts may be hindered by a lack of equipment or a need to train frontline staff.

Healthcare Commission chief executive Anna Walker says national trends would be easier to analyse if "serious untoward incidents" were collated by the same body. Currently, NHS trusts report such incidents to strategic health authorities, the independent sector reports them trusts go to Monitor. Even the definition of such an incident varies according to organisation.

Ms Walker feels "passionately strongly" that all this information should be nationally pooled, although she says she does not mind who takes on the task. However, she adds: "It wouldn't be sensible for Monitor to do it because it's concerned with foundation trusts. We could collect it, or the Information Centre."

Culture of denial

Clinicians' attitudes were also felt to play a part in the scale of problems going unreported. Over half of respondents - 58 per cent - felt there was a "culture of denial" among clinicians regarding patient safety incidents. The Department of Health's 2006 Safety First report said the NHS needed to focus on changing this.

Mr Fletcher says the survey's figures reflect the fact that spending 10 minutes filling in an incident report form after a busy shift is not always a top priority for clinicians, meaning more work needs to be done to speed up and simplify the process. It is particularly important to target doctors, he says, as there "is probably more of a tradition of incident reporting in nursing than medicine".

Despite the perceived culture of denial among clinicians, when HSJ asked people to rate different staff groups for their contribution to patient safety the highest number of top scores were given to nurses, followed by doctors and healthcare assistants. Cleaners got fewer good scores than these groups. Managers came last.

When it came to who got the most bottom scores, 14 per cent of respondents gave managers a bottom mark and a quarter of respondents gave cleaners one out of five.

Just over half of those surveyed agreed clinicians were leading patient safety at their trust, although 17 per cent disagreed strongly. One respondent, from an acute trust, said: "Many clinicians I meet feel powerless or are unmotivated to really influence things."

The most recent NHS staff survey by the Healthcare Commission, published last month, showed the amount of reporting is increasing. But problems remain in primary care, where risks in areas such as general practice can be difficult to identify. This looks set to improve after the new regulator, the Care Quality Commission, becomes active next April, when NHS GPs are likely to be independently regulated and inspected for the first time.

Meanwhile, patient safety appears to be high in most boards' priorities: nearly two thirds of respondents agreed strongly that patient safety underpinned every decision made at their trust. However, 33 per cent disagreed, of which 15 per cent strongly disagreed.

An acute trust middle manager said: "Boards still do not have patient safety at the heart of their agenda, they just talk the talk. You feel you are banging your head against a brick wall."

A third of respondents from mental health trusts disagreed strongly that patient safety was high in their boards' priorities - a markedly higher proportion than in other sectors. One mental health trust doctor told the survey: "Development to foundation trust status takes precedence over reported safety issues."

Most people said finances had most trust board attention, then government targets, clinical issues, infection control and workforce.

Only 12 per cent of people said infection control received the most attention from their trust board and there were concerns over the funds and facilities available to prevent infection outbreaks. And while 46 per cent of surveyed chief executives agreed strongly that their trust had sufficient resources to restrict the spread of healthcare-acquired infections, only 15 per cent of middle managers did.

Half of the chief executives surveyed disagreed with the statement "patient safety is at the core of the government's NHS policies". Only 8 per cent agreed strongly and more than twice as many disagreed strongly. Half the doctors and 30 per cent of trust directors disagreed strongly.

An acute trust middle manager said: "I think the government focus on targets severely restricts the consideration of patient safety. In moving patients around the trust to meet targets such as A&E waits, decisions are often made based on clock-watching rather than clinical need."

A non-executive director at an acute trust said: "Patient safety and care is currently a target-driven agenda and it's failing. It needs to evolve rapidly into wholesale cultural change with far greater empowerment at ward level and far greater clinical engagement."

The future's bright

Overall people were optimistic, however, with 60 per cent agreeing that the NHS is becoming safer for patients every year. But more than half said patients and carers do not play an integral part in developing safety initiatives at their trust.

This is despite a call in Safety First for "patients, health professionals, policy makers and healthcare leaders... to work together to prevent avoidable harm in healthcare".

The report states: "Patients and their families have a unique perspective on healthcare and may provide information and insights that healthcare workers may not otherwise have known."

This is being partly addressed by recruiting 22 patient champions - volunteers who will work with trusts to ensure patients are considered in every safety decision - across England and Wales. They are due to start work this month.

However, there are simpler ways in which trusts can involve patients, according to Don Redding, head of policy and communications at the Picker Institute, which promotes the understanding of patients' perspectives.

He says: "Patient involvement in patient safety could be extremely effective but is often neglected. There is clear evidence that if a hospital encourages patients to directly ask the nurses and health professionals whether they've washed their hands, it's very effective."

Enabling patients to check the accuracy of their own medical records also increases patient safety.

"The more we can involve patients in understanding the problems and potential effects of medicines, the better."

Where does accountability lie?

On the question of who is responsible for patient safety in each trust, several people said the chief executive or trust board, while other replies ranged from "medical and nursing staff" to "everyone".

Health Foundation chief executive Stephen Thornton identifies two distinct sets of accountability, one covering "the system", which is down to management, and the other covering personal, clinical and professional duties, where "fairly and squarely we can put the responsibility on the individual".

Many incidents appear due to systemic failings rather than personal negligence, which people are less likely to report. National Patient Safety Agency figures show that in 2006-07 the top 10 incidents included "infrastructure", "documentation" and "consent, communication, confidentiality".

Key points

• A quarter of healthcare respondents to HSJ's survey knew of a patient safety incident in the past year.

• Over half said clinicians led on patient safety at trusts.

• Different types of organisation report untoward incidents to different bodies, and definitions vary.

• This month 22 "patient champions" will start to work with trusts to consider patients in safety decisions.

For information on the Health Foundation's patient safety initiative, visit the Good Management section

HSJ's Patient Safety Congress 2008 takes place on 22-23 May. After the event content will be available from www.patientsafetycongress.co.uk