Several years late, NPSA publishes patient safety incident reports – but where’s the learning?

The National Patient Safety Agency (NPSA) was launched in 2001 as “the engine for learning.” But of all the Department of Health agencies it has had a particularly troubled history, especially in relation to it’s inability to deliver on some of the key objectives originally set for it.

Almost 8 years after its launch, however, the NPSA is now providing the public with patient safety incident reports from NHS organisations. Anyone can access these reports by clicking here.

Unfortunately, the reports contain no information for learning, i.e. information based on root cause analysis (RCA e.g. see the recent post describing the New Zealand report on learning from serious and sentinel events, here). You can get a percentage breakdown of types of incidents reported by the organisation and degree of harm to patients. You can get a ‘reporting rate’ (i.e. number of incidents per 100 admissions). You can get a monthly breakdown of the number of incidents reported over a 12 month period. And you can see a reporting rate comparison graph showing the organisation relative to other similar organisations. In other words, what you get is nothing more than the results of what appears to be some big ‘accounting’ exercise.

Healthcare Governance Review is struggling to understand how this information helps trusts implement evidence-based strategies for improving patient safety. If any readers can helpfully explain, please post your comments below.

In the meantime, you might be interested in what the Health Service Journal says about the reports here.

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