Dramatic rise in number of medical mistakes involving NHS patients

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There has been a dramatic rise in the number of medical mistakes involving NHS patients, with more than twice as many incidents reported to the official watchdog over a three-year period.

The National Patient Safety Agency says in a report published yesterday that the number of reported incidents involving errors and “near misses” in patient care has risen significantly in recent years.

In 2007, the last year for which data is available, there were 86,085 reports of medication incidents involving the incorrect administration of drugs and treatments. This compares to 64,678 medication incidents reported in 2006 and 36,335 incidents reported in 2005.

The safety agency said that the vast majority – 96 per cent – of these incidents did not result in any serious harm to the patient involved. Only 100 of the reported incidents resulted in serious injury, and of these, 37 contributed directly to the death of the patient, it said.

Martin Fletcher, the chief executive of the patient safety agency, said that the increase in reported incidents reflected a willingness on the part of NHS staff to admit their errors and report them to the appropriate authorities.

“Millions of medicines are prescribed in the community and in hospitals across England and Wales each day. The majority of these are delivered correctly and do exactly what they are meant to do,” Mr Fletcher said.

“However, when an incident does occur, it is vital we learn from this to ensure patients are not harmed,” he said.

Acute care departments in hospitals continued to be the highest reporters of all medical mishaps, accounting for 73 per cent of all incidents and 76 per cent of incidents involving incorrectly administered medication.

The most serious incidents were caused by errors in the administration of medicines – 41 per cent of the total – such as measuring the wrong dose or administering by the wrong route. About a third of the medication mishaps were caused by prescription errors, the report says.

“Incidents involving injectable medicines represent 62 per cent of all reported incidents leading to death or severe harm,” it says. Seven out of ten fatal and serious mishaps involving medication were due to the wrong dose, wrong medicine or a failure to give a medicine on time, the report says.

Sir Bruce Keogh, NHS Medical Director, said that the vast majority of NHS patients receive good quality, safe and effective care. “We have learnt from industries such as aviation that scrupulous reporting and analysis of safety-related incidents, particularly ‘near misses’, provides an opportunity to reduce the risk of future incidents,” Sir Bruce said.

The report says: “Organisations that have poor reporting culture and systems where few medication incidents are reported may be at greater risk of harming a patient with a medicine as there is less opportunity to learn and improve their medication systems.”

Liberal Democrat health spokesman Norman Lamb said that settling claims for damages resulting from mistakes costs the NHS nearly £1bn per year – money that could be spent on patient care.

“In an organisation the size of the NHS there are always going be some accidents, but we have to ensure that robust systems are in place that minimise risks and prioritise patient safety,” Mr Lamb said.

“The fact that some errors are being made over and over again needs to be looked at much more closely. It is vital that the NHS has a robust and rigorous reporting culture so that mistakes can be rectified as soon as they are made,” he added.

The patient safety agency’s report says that there was no repeat of the fatal incidents involving the accidental injection of potassium chloride and the oral administration on of methotrexate, highlighted in its previous reports.

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