New 'health tsar' Shaw will head investigations into NHS mistakes

The latest in a long line of discredited Government tsars was appointed yesterday to take responsibility for the safety of NHS patients.

Professor Rory Shaw was named as the first chairman of the National Patient Safety Agency, an independent body which will collect information about mistakes and near-misses by health service staff.

The move is part of a drive to reduce the number of medical errors that occur each year and boost patients' confidence in doctors.

The agency, which expects to open for business in 2002 to collate reports sent by NHS trusts, GP's surgeries and community services, expects to deal with an estimated 850,000 'adverse incidents' a year, including between 60 and 180 'serious' incidents in a typical NHS trust.

It will have the power to issue reports and recommendations to ensure errors are not repeated.

Prof Shaw, medical director at Hammersmith Hospital, west London, said the agency would help create a culture of sharing information in the NHS so health professionals could learn from their mistakes.

The Bristol inquiry report, published last month, said doctors should be immune from disciplinary action if they quickly reported mistakes which could have harmed a patient. It also called for hospitals to have confidential reporting systems.

The agency has already begun issuing 'patient alerts' about specific problem areas on a web site and aims to begin meeting targets to reduce the number of avoidable deaths and injuries from medical errors or negligence.

Prof Shaw said: "In a very large organisation like the NHS there are always opportunities for clinical management to go wrong and for mistakes to happen. Managers need to understand how they happen and learn from them.

"Many hospitals do this already very well. The plan is to build on this and make sure the whole NHS benefits."

Over the next six months, trials will take place to devise the best system for passing on information about mistakes and near misses locally and to the agency.

Doctors, nurses, managers and patients will be encouraged to pass on information in writing or by computer.

In Prof Shaw's own hospital, managers have set up a cyber cafe where staff can log on to a computer network and fill out a form detailing their complaints.

The new agency plans to target 'regular patterns of error' to reduce the risks to patients and aims to reduce to zero the number of patients dying or being paralysed by wrongly-administered spinal injections.