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Monday 21st May 2018

National Patient Safety Agency

13th March 2007

With another report published in December finding the NPSA wanting, we look at the agency’s chequered first five years, and what the Department of Health is now planning to do with it.


What is the NPSA?

The National Patient Safety Agency (NPSA) was created in 2001 as a result of the Chief Medical Officer’s report ‘Organisation with a Memory’ which brought a national focus to, and galvanised action around, patient safety in a way which had not been done before.   Patient safety incidents include medication errors, equipment failures, patient accidents such as trip and falls, and wrong-sided surgery to name just a few examples.  The NPSA was seen as the answer to the following problem for the NHS each year:

• Just under one million incidents or near misses – affecting one in 10 patients admitted to hospital – over 2000 of which result in a patient death

• £400m in settled negligence claims

• £2bn in extra bed days

It has been suggested that around 20% of incidents and 40% of near misses go unreported, with doctors the least likely to report.  There are significant variations between trusts in levels of reporting, and only a quarter of trusts tell patients as a matter of course when things have, or have nearly, gone wrong.  It is thought that 50% of all patient safety incidents could be avoided if lessons were learned from previous incidents.  All this at a time when patients are demanding more and more information about patient safety, as they exercise choice over which healthcare provider they want to use.

The NPSA’s purpose when it was set up was to enable an improvement upon these statistics through better reporting, analysis and learning from incidents and near misses.  Before its creation, around 30 different regulatory bodies were involved in the process. The NPSA’s role until now has been to:

• Establish a single route for the mandatory reporting of incidents and near misses through the National Reporting & Learning System (NRLS)

• Assimilate and disseminate wider safety-related information

• Learn lessons from patient safety incidents, develop solutions to prevent their re-occurrence, and pass these on to trusts for implementation

During the Department of Health’s review of all its Arms Length Bodies, the NPSA has retained its core remit, but picked up the following additional responsibilities since April 2005:

• Safety aspects of hospital design (from NHS Estates)

• Cleanliness and food in hospitals (from NHS Estates)

• Central Office for research ethics committees (COREC) – ensuring the safe undertaking of research activities

• National Clinical Assessment Service (NCAS) - supporting local organisations in concerns over the individual performance of doctors and dentists

• Managing the contract for three confidential enquiries – CEPOD, CEMACH and NCISH

How has the NPSA been doing?

A series of reports have been highly critical of the progress the NPSA has made against its objectives, and its job-share Chief Executives – Sue Williams and Sue Osborn – have been on ‘extended leave’ since August.
The National Audit Office reviewed patient safety issues in the NHS between 2003 and 2005, publishing A Safer Place for Patients in November 2005.  It concluded that whilst the safety culture was improving in the NHS, better feedback from the NRLS was required to enable systematic learning from incidents.  It found that there was also patchy, and often delayed, compliance with Safety Alerts issued by the NPSA to healthcare providers.

The Commons Public Accounts Committee reported similar shortcomings in July 2006, concluding that the NPSA was offering poor value for money.  It found that the NRLS - which should have been set up and producing quarterly feedback reports by December 2001 - only produced its first report in July 2005, and that the NPSA’s development of solutions to safety incidents was still limited.  The Committee recommended that the Healthcare Commission might have a greater role in monitoring reporting practice and action against Safety Alerts.

Most recently, the Department of Health’s own review of patient safety (Safety First published in December 2006) concluded that, despite receiving 60,000 incident reports per month, the NRLS is still not offering high quality routinely available information on patterns and trends, and is not resulting in ‘actionable learning’ for local providers.  The review found that there were still a number of other agencies involved in improving patient safety and reporting alongside the NPSA, and their respective roles were not clear.

What is now being proposed for the NPSA?

Having gained additional responsibilities through the review of Arms Length Bodies back in 2005, key recommendations from Safety First now are that the NPSA should:

• Re-focus on its core activity of collecting and analysing information through the NRLS, using it to inform rapid learning across the NHS
• Simplify the NRLS to make reporting easier

• Look to commission other NHS organisations (such as NICE and the NHS Institute for Innovation and Improvement) to develop technical and organisational solutions to patient safety weak points, rather than necessarily developing those solutions itself
The Chief Medical Officer, Sir Liam Donaldson, has since endorsed this proposal for a slimmed down NPSA to focus on these tasks.

Other recommendations coming out of Safety First report include the following:

• Patient Safety Action Teams proposed for each SHA to devolve expertise from the NPSA to a more local level

• A new National Patient Safety Forum is about to meet for the first time, including the NHS Chief Executive and Chief Medical Officer, which will bring together and co-ordinate all agencies involved in patient safety matters including the NPSA
A summit of various bodies involved in patient safety was hosted by the NPSA and Healthcare Commission on 22 February where they made a public commitment to making patient safety issues more of a priority, and to working together to improve safety of care.


For more information about the NPSA and recent reports into it, go to:




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