The NHS has forgotten to ensure that it has an adequate system to tackle “giant risks” that cause harm to patients, says the former head of medication safety at NHS England.
In an insight article written for The Pharmaceutical Journal
, David Cousins, former head of safe medication practice at the National Patient Safety Agency (NPSA) and NHS England, claims the drive — launched in 2000 by then chief medical officer Liam Donaldson — to ensure the NHS was an “organisation with a memory” was being eroded.
Cousins says that the current focus of the health service is to identify “new and under-reported patient safety issues”, rather than seeking to prevent long-standing issues that cause the most harm. He adds that medication safety is a particular issue in the health service and that the NPSA used to publish more detailed data regarding this and “learning on major risks to safe medication practice”, which had stopped under NHS Improvement.
He cites data — obtained by him through a freedom of information request — which show that the medication incidents reported by NHS in England included wrong or omitted medicine doses (especially for opioids, anticoagulants and insulin); unsafe use of injectables; wrong medicines use; and medicines given to patients who were allergic.
Cousins cites a board paper from NHS Improvement — the body that has been responsible for patient safety programmes since 2016 — which outlines the action it takes on the basis of data from the National Reporting and Learning System (NRLS). The paper said that most patient safety challenges are “well recognised” and that these “giants of patient safety” are the focus of long-term NHS programmes.
However, in his comment piece, Cousins says: “Although this is worthwhile, there is very little current information concerning the identity and number of reports to the NRLS of ‘giant’ risks to patient safety. There is also no information describing long-term programmes intended to address these risks. There is a danger that the ‘organisation with a memory’ is developing memory loss and is not addressing risks that account for the harms most commonly reported to the NRLS.”
NHS Improvement said that this characterisation was “simply not right”.
In a response to the comment piece, Aidan Fowler, NHS national director of patient safety, said: “As an improvement organisation we are keen to listen to feedback and are committed to helping the NHS become the safest healthcare system in the world, which includes building on the important work of the NPSA.
“However, it is simply not right to suggest that the NRLS — the world’s largest patient safety incident reporting system — is not supporting learning or transparency. We are now developing plans to replace the NRLS with the Patient Safety Incident Management System, which will enable us to hear directly from patients and to learn from incidents more quickly.”
The drive includes supporting pharmacies in acute hospitals to provide a 24/7 service, using electronic prescribing to improve medicines safety, placing pharmacists in care homes and publishing indicators on medicines safety.