Learning the lessons from patient safety errors of the past

By John Tingle

A common theme found in patient safety reports in England going back as far as the year 2000 is that the NHS (National Health Service) is poor at learning lessons from previous adverse health incident reports and of changing practice. The seminal report on patient safety in England, Organisation with a memory in 2000  stated:

“There is no single focal point for NHS information on adverse events, and at present it is spread across nearly 1,000 different organisations. The NHS record in implementing the recommendations that emerge from these various systems is patchy. Too often lessons are identified but true ‘active’ learning does not take place because the necessary changes are not properly embedded in practice.” (x-xi).

In late 2003 our NRLS (National Reporting and Learning System) was established.This is our central database of patient safety incident reporting. Can we say today that the NHS is actively learning from the adverse patient safety incidents of the past and changing practice? That the NRLS has been a great success? Or is the jury still out on these questions? Unfortunately the jury is still out. Sadly, there is no shortage of contemporary reports saying that the NHS still needs to improve its lesson learning capacity from adverse events.

Worryingly in 2015 the House of Commons Public Administration Select Committee (PASC) report into investigating clinical incidents in the NHS stated:

This failure to learn from incidents and disseminate lessons has been a long –standing weakness of the NHS…. “(p.45)

NRLS Reform

A key tool in our patient safety system is our NRLS. The NRLS is being reformed to make it much more fit for purpose as several failings have been identified which include complexity and coverage.

A DPSIMS (Development of the Patient Safety Incident Management System) project is currently underway in the NHS which will succeed the NRLS. The NRLS currently receives over two million incident reports each year.

New patient safety report published.

NHS improvement  have provided a summary of how they reviewed and responded to the patient safety issues identified in the reports sent to them through the NRLS. These reviews are six monthly summaries and provide an important learning resource for NHS staff on current patient safety issues. In the six months covered by this report NHS Improvement clinical teams reviewed 9,769 NRLS incident reports with an outcome of death or severe harm (including reviewing each update).The report also gives examples of the actions that NHS Improvement took through routes under than alerts during the period covered by the report and cases included:

  • Diagnosing and treating testicular torsion
  • Delays in urgent surgery for children and young people
  • Wrong tooth extraction. From April 1, 2016 to March 31, 2017 (provisional date) there were according to the report, 42 wrong tooth/teeth extractions among 178 reported wrong site surgeries. Thirteen of these were in the under 18 age group.
  • Entanglement of babies and infants in intravenous (IV) lines or nasogastric (NG) tubes
  • Eye injury (orbital apex syndrome) in patients in the prone position in critical care
  • Patient found asphyxiated after slipping under a wheelchair waist belt
  • Wrong route administration error: oral vaccine given parentally
  • Silver nitrate sticks confused with cotton buds

The reports sent to the NRLS are clearly informing NHS Improvement patient safety policy. The key to developing an ingrained patient safety culture however is that lessons are learnt and practices changed at the local workforce level. NHS history has shown that this is generally a very difficult thing to achieve.

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