60,000 'harmful NHS incidents' last year

Published on Monday 11 May 2009 22:11

MORE than 60,000 incidents which may have harmed NHS patients or staff were reported in Scotland in the last year.

Figures obtained by The Scotsman found that 64,537 so-called "adverse incidents" were recorded by health boards in the space of a year.

But experts said the actual figure would be much higher and staff needed to be more willing to report when something went wrong during a patient's care in order to improve the system.

Adverse incidents can range from minor accidents, such as someone suffering a paper cut, to serious infections, falls and, in some cases, deaths.

But each board differs slightly in their definition of what an adverse incident is and there is currently no central database in Scotland to report such events.

Dr Jason Leitch, Scotland's national clinical lead for patient safety, said boards with the highest number of recorded incidents may actually be the safest as staff felt more able to report when something went wrong.

He said as reporting of adverse incidents increased, the number of really serious failures should fall.

While definitions of an adverse incident varied slightly, most boards described it as an incident in the course of care that "could have or did lead to unintended or unexpected harm, loss or damage" to patients, staff or the public.

Reporting of such incidents varied widely between boards.

Ayrshire and Arran reported 12,477 incidents in 2008, while Lothian – one of the country's biggest boards – reported 3,107 in 2008/09.

NHS Greater Glasgow and Clyde last year reported 3,666 "clinical incidents" – those directly related to patients' treatment as opposed to the wider definition used in other areas.

The majority of boards showed a rise in reported adverse incidents in the last three years as systems of recording have improved.

While there were almost 65,000 incidents recorded across 12 health boards, a further 9,573 "near misses" were also reported – cases where something almost went wrong but was avoided.

NHS Western Isles and Forth Valley failed to supply figures.

Dr Leitch said adverse incidents could range from someone cutting their finger up to people getting serious infections like Clostridium difficile.

"Most of the developed world talks about one in ten patients being harmed at some point during their care," he said.

"We have no reason to believe we are any worse or any better than that number."

Dr Leitch said he expected the number of adverse incidents reported to rise, as people felt more willing to come forward.

"If you look at the organisations who have been through this culture change – if you look at the airline industry – as they reduced their deaths from major incidents, their reporting numbers went up. As the culture changed, people were more willing to say 'I did this or that'. But their deaths and serious injuries plummeted."

Dr Leitch said boards with large numbers of incidents reported may have the best culture for allowing staff to speak out.

In many cases, he said the system of providing care may be at fault rather than individuals. Adverse reactions to drugs would also be included. He said Scotland was leading the way in reducing adverse incidents.

Margaret Watt, chair of the Scottish Patients Association, said: "I think there are a lot of people frightened to complain. I think there is a lot more going on than we know about but it is hidden."

A British Medical Association Scotland spokeswoman said: "Like any large organisation, the NHS experiences errors and near misses. Medicine is not an exact science and it cannot be error free. It is important that the NHS has sensible and good risk management procedures."

A Scottish Government spokesman said:

"We would expect any adverse incidents or 'near misses' to be taken seriously by health board authorities, with appropriate investigation and disciplinary action taken where necessary."