Reports: 418 ‘serious events’ at Scots hospitals

HUNDREDS of serious adverse events in Scottish hospitals have been reported in the first in a series of reports into how health boards handle and learn from mistakes.

Healthcare Improvement Scotland (HIS) published four reports yesterday into NHS Fife, Forth Valley, Western Isles and the State Hospital.

The boards together reported more than 400 significant adverse events over a period of 18 months, along with thousands more less serious incidents.

An adverse event is described as “an unexpected or avoidable event that could have resulted, or did result in, unnecessary serious harm or death of a patient, staff, visitors or members of the public“.

The reviews, which will cover all health boards in the coming months, were ordered by the Scottish Government last year after it emerged that NHS Ayrshire and Arran had withheld reports on serious incidents.

A member of staff complained to the information commissioner which revealed the health board had not released more than 50 reports. These covered events at hospitals and clinics, including 20 patient deaths.

The HIS reports yesterday said as of September 2012, NHS Fife had recorded 15,255 adverse events over a period of 18 months.

The board reported that 81 of these were categorised as significant adverse events and had either been investigated or were in the process of being reviewed.

In NHS Forth Valley, between February 2011 and the end of June 2012, a total of 12,513 incidents were reported. The NHS board assessed 239 of these as high or very high, and provided details of a further 60 incidents that had occurred in this period that they had re-graded as high or very high.

Between January 2011 and end of July 2012, NHS Western Isles recorded 1,338 adverse events. The board reported that 25 of these were categorised as serious untoward incidents and had either been investigated or were in the process of being reviewed.

In the State Hospital, 13 incidents were subject to critical incident review or serious untoward incident review.

After looking into how the boards dealt with the errors, HIS made a series of recommendations including improving staff training to handle incidents and making sure patients and families are kept informed of developments in investigating their cases.

A spokesman for HIS said: “The publication of these reports marks the first stage of a programme of reviews we are conducting across NHS Scotland.

“In these first reports we highlight areas for improvement and areas of good practice relating to the management of adverse events across the four NHS boards reviewed.

“A key finding of our work to date is that a positive reporting culture is essential to reduce the risk of adverse events happening again.

“As the review programme progresses, we will continue to provide feedback on our findings across NHS Scotland and use this information to inform and shape the development of the national approach to adverse event management.”