November 3, 2005
by James Tozer
Medical blunders kill an estimated 34,000 patients a year, according to an official report.
Almost one million incidents and lapses in hospital care were recorded in the latest survey of National Health Service standards.
Some 300,000 episodes of hospital infections, including MRSA, were also reported, said the National Audit Office.
It said the lapses cost the Health Service an estimated £2billion in extra bed days and £540million in litigation and compensation.
The report said 2,081 avoidable deaths had been reported for April 2004 to March 2005. But because many deaths went unrecorded the real figure based on previous research could be nearer 34,000.
Hospital infections alone are thought to kill 5,000 patients every year.
The number of blunders could have been halved if staff had learned from earlier errors, the report said. Some doctors were found to be reluctant to talk openly about mistakes and accidents for fear of being blamed.
The report highlighted equipment failures and mistakes by staff that led to accidents, falls and medication overdoses.
Some health trusts were not reporting incidents to the National Patient Safety Agency which had itself been slow to act on problems, added the report.
Tory MP Edward Leigh, chairman of the Commons Public Accounts Committee, said: "No public health system should tolerate a failure to learn from previous experience on this scale. It is unacceptable that any NHS staff member might be too afraid to report things going wrong.
"It cannot be right that when they do want to report an incident staff have to waste valuable time reporting it to more than one safety organisation.
"Although the National Patient Safety Agency was set up to ensure that valuable lessons learned from patient safety incidents could be analysed and shared both locally and nationally there is limited evidence of any effective activity." The audit office's Karen Taylor said: "We just don't know how many deaths are involved. We don't have this information.
"Every day more than one million people are treated successfully in the NHS but sometimes things do go wrong." Only one in four health trusts routinely tells patients or their families about a clinical 'near-miss'. Twothirds of these incidents led to no long-term harm for the patient.
"Trusts are still predominantly reactive, large pockets of blame culture still exist and staff are not being encouraged or feeling free to report these incidents," added Miss Taylor.
She said 35 hospitals had failed to sign up to a new patient safety reporting system.
And only 4 per cent had been rated as having the best systems in place to protect patients.
Bill Kirkup, Deputy Chief Medical Officer, said: "The majority of these incidents are minor and have no lasting effect on patients.
"Regrettably, some are more serious. We must investigate and learn from all of them, so that we can make systems safer and more reliable. Similar rates of patient safety incidents occur in every health service.
"We are leading the way worldwide having set up the National Patient Safety Agency and established a reporting and learning system to encourage open reporting and implementation of improvements in the NHS."