§ Bob SpinkTo ask the Secretary of State for Health (1) if he will make a statement on the Serious Hazards of Transfusion report (2000–01); and what strategy he has to reduce the number of mistakes made in patient identity. [73030]
(2) what action he has taken following the SHOT report to adopt new systems and technology to prevent patient identity errors. [73114]
(3) what (a) strategies, (b) systems and (c) technologies he plans to introduce to reduce the number of adverse patient incidents in the NHS; and if he will make a statement: [73045]
(4) if he will make a statement on the Spoonful of Sugar medicine management in NHS hospitals, Audit Commission report of December 2001, and what strategy he has to reduce the human and financial costs of mistakes in the NHS. [73029]
(5) if he will make a statement on the National Patient Safety Agency 17 June report; and what strategy he has for reducing the percentage of NHS hospital admissions that experience adverse incidents caused by human error; [73044]
(6) wh at estimate he has made of the overall cost to the NHS of adverse patient incidents in each of the last five years for which figures are available; [73115]
(7) what estimate he has made of the number of NHS beds lost due to adverse patient incidents in each of the last five years. [73116]
§ Mr. LammyThe Department does not collect information on the number of extended hospital stays as a result of adverse events nor figures on their financial cost. However, as reported inAn Organisation with a Memory—a report of an expert group on learning from adverse events chaired by the Chief Medical Officer, it is estimated that there may be around 850,000 adverse events each year in the National Health Service which research suggests may lead to three million preventable additional hospital bed days. It is estimated that extended hospital stays as a result of adverse events costs the NHS approximately £2 billion a year.
The Government established the National Patient Safety Agency in July 2001 to improve the safety of NHS patient care by promoting a culture of reporting and learning from adverse events, and to manage the national reporting system to support this function.
By collecting and analysing data on adverse events the agency will be able to identify trends and patterns of avoidable adverse events, provide feedback to organisations to enable them to change their working practices, help develop models of good practice and systems solutions at national level and support ongoing education and learning.
From September 2001 the National Patient Safety Agency ran a pilot in a small sample of trusts designed to test the system for collecting data on adverse incidents and near misses from the NHS.
On 18 June 2002, the National Patient Safety Agency held a conference and presented initial findings of the pilot. The results of the data collection are preliminary 410W and few conclusions can be drawn from this data at this stage. The agency will publish audited figures when they are available. The agency will be working to implement a national reporting system across the NHS from 2003.
This will provide us with a firm evidence base on the scale of the problem and its financial consequences—a baseline allowing us to understand the real extent and nature of adverse events, and act on that knowledge.
The Department has set a specific target which requires the NHS by 2005 to reduce by 40 per cent. the number of serious errors in the use of prescribed drugs. The Department will shortly be publishing a report highlighting processes and individual medicines that are commonly involved in medication errors. The report will also identify a range of measures that professionals and NHS organisations can use to systematically drive down the risk of medication errors across the NHS.
The Department has broadly welcomed the Audit Commission's report on medicines management in NHS hospitals, A Spoonful of Sugar. Chief pharmacists and their staff play a key part in medicines management and it is helpful to see this role highlighted. The report reinforces the Department's medicines management performance management framework.
§ Ms BlearsThe fifth report (2000–01) on the serious hazards of transfusion (SHOT) was published on 10 April 2002 and again indicated that blood transfusion in the United Kingdom is very safe, and amongst the safest in the world. Although the number of serious events reported, 315, had increased by 7.5 per cent. this must be seen against a total of over three million blood components transfused annually and increased participation in the scheme. Since the previous report, for 1999–2000, participation in SHOT by National Health Service (NHS) trusts has increased from 72 per cent. to 92 per cent. of all hospitals. We will be looking to SHOT and the new national patient safety agency to help us take a more comprehensive approach to improving patient safety in the NHS.
We are committed to modernising the NHS and working on systems that are shown to reduce error in clinical practice, are safe, and capable of being used effectively and universally. To this aim, there are pilot projects looking to improve the identification of patients and issue of the correct blood. The results will help to inform future research and developments in this area to improve patient care.
In July 2002 new guidance was issued to the NHS on "Better Blood Transfusion—Appropriate Use of Blood" www.doh.gov.uk/publications/coinh.html. This sets out a programme of action for the NHS to; ensure that Better Blood Transfusion is an integral part of NHS care. The guidance includes an objective to improve the safety of the blood transfusion process and calls on the NHS by December 2002, to ensure that policies on patient identification are in place, implemented and monitored throughout the blood transfusion process from prescription, sampling, laboratory testing and issue of blood to collection and administration of blood transfusion.
§ Bob SpinkTo ask the Secretary of State for Health what(a) technologies and (b) systems he plans to introduce in the NHS to reduce the risk of the wrong drugs or inappropriate quantities of drugs being given to patients; and if he will make a statement. [73118]
411W
§ Mr. LammyIt is recognised that the manual writing of prescriptions and the manual dispensing of drugs is associated with a significant error rate. Measures to combat this include the following.
In primary care technologies are already in place within general practitioner's (GP's) clinical practice system to help identify the risks involved in prescribing of drugs to patients. PRODIGY is a computer-based decision and learning support system contained within the GP practice system, which offers a series of recommendations in prescribing and organisation of treatment for conditions.
In secondary care information for health the strategy for information services in the National Health Service recommended the introduction of electronic records into all acute trusts. Electronic prescribing systems were specifically mentioned as part of those electronic records. It is intended by 2008 that all acute trusts will have electronic prescribing systems, most acute trusts by 2005. The use of these systems will lead to a reduction in errors that can occur.
In the pharmacy, "Pharmacy in the Future—Implementing the NHS Plan", emphasised the need to re-engineer hospital pharmacy services to be more efficient, timely and safe and more patient focussed. Use of modern automation technology was seen as one way of facilitating this. This was reinforced in the Audit Commission report "A Spoonful of Sugar". Consideration is currently being given to the commissioning of a national specification for automated dispensary systems for the NHS and earmarking of funding for their introduction.
§ Bob SpinkTo ask the Secretary of State for Health what estimate he has made of the level of compensation to be budgeted for by the NHS in respect of adverse patient incidents in the(a) current and (b) next financial years. [73117]
§ Mr. LammyCompensation is only paid where there is a liability to do so, and payments are usually made following settlement of clinical negligence claims. According to the National Audit Office Summarised Accounts for the National Health Service (2001) a provision of £4.4 billion was calculated for liabilities relating to all current clinical negligence claims and ones which may arise from incidents which have incurred but not yet been reported. These liabilities will include compensation as well as legal and other costs which are not identified separately in the accounts.