Patient safety matters

The debate surrounding patient safety is clearly one that is now of interest to a diversity of voices, judging by the number of organisations and individuals that responded to the Health Select Committee’s current inquiry into patient safety¹. The inquiry comes at the end of a year which marked the 60th anniversary of the NHS and when the European Commission is currently developing a proposal that will address the issues of general and systemic patient safety concerns.

MPS believes that the underlying cause of the majority of adverse incidents in medicine is either systems failure, or a combination of systems failure and individual error. Only a minority of adverse incidents are solely caused by individual failure or poor clinical judgment.

Our experience is that a significant proportion of adverse incidents are avoidable. Among the recommendations that we asked the committee to consider in our written evidence were ways to improve patient safety in out-of-hours (OOH) services in primary care and through risk management interventions.

OOH services

Changes to the organisation and delivery of primary care services have brought new patient safety risks, particularly in OOH services. MPS is the largest indemnifier of OOH providers, which overall cater for a population of around 32 million people. Currently, patient care is provided by OOH services for 70% of the week (ie, Monday-Friday, the hours outside normal GP surgery opening times (6.30pm-8am); Saturdays, Sundays and bank and public holidays).

MPS carried out a review of complaints relating to OOH services over a six-month period during 2006 and found that wrong or delay in diagnosis was the most common cause of dissatisfaction with OOH services².

In our view, the wide variety of commissioners and suppliers of OOH services means that it is difficult to apply common standards. Therefore, we recommend that all OOH providers should be required to undertake regular independent risk assessments and implement comprehensive training and induction programmes. A greater focus should be given to the provision of OOH care, including a reassessment of national standards.

Finally, we would like to see more research carried out into the root cause of complaints relating to OOH care, so that lessons can be identified and learned more effectively.

Risk management interventions

Although there is general agreement that interventions aiming to reduce adverse incidents improve patient safety, there is very little evidence supporting this. Therefore, we believe that one of the most important next steps for patient safety is for the government to commission research, to examine the extent to which risk management interventions are successful and cost-effective in reducing the impact of adverse incidents.

In addition, we believe that there is a need to include a greater emphasis on patient safety and risk management in the medical undergraduate and postgraduate curricula – currently, there is no requirement for it to be covered. We would also support mandatory, consistent and comprehensive induction programmes for all new healthcare staff. They should be consistent and comprehensive in content and quality and should include training in clinical governance and risk management.

Patient safety has been at the top of the political agenda for some time and it seems unlikely that this will change in 2009 - we hope, therefore, that the Health Select Committee will have the opportunity to explore these issues during its inquiry.

References

1. MPS submitted written evidence to the Health Select Committee’s inquiry (memorandum HC1137 of Session 2007-08)
2. Price J, Haslam J, Cowan C, Emerging Risks in Out-of-hours Primary Care Services, Clinical Governance: An International Journal, 11;4 289–98 (2006)