Final Report > Chapter 26: The Safety of Care > Introduction

Introduction

1 In this chapter we are concerned with safety: that the care which patients receive will be safe. This is not just something which patients are entitled to; it is something they take for granted. But Bristol teaches us that this trust may be misplaced. Care may not be safe. Thus in what follows we examine: what safe care involves; what action is needed to ensure a higher and more consistent degree of safety for patients in the future; and what barriers stand in the way of achieving this.

2 The complexity of modern medical care makes it an increasingly risky enterprise. While the vast majority of patients receive safe treatment, it comes as a surprise to many to know that errors, mistakes or accidents occur every day in every corner of the NHS. These have become known collectively as adverse events. [2] They are often grouped together with another category of event called `near misses', a term which is self-explanatory and is borrowed from the airline industry. So as to avoid the distractions associated with allocating an event to one or other of these categories we propose, later in this chapter, that a single term, `sentinel event', be used in the future. In describing current practice, however, we use the term `adverse event'. We referred in Chapter 21 to the recent pilot study carried out by Professor Vincent. It suggested that around 5% of the 8.5 million patients admitted to hospitals in England and Wales experience an adverse event which may be preventable with the exercise of ordinary standards of care. [3] We accept the authors' caveat about the difficulties of generalising from a pilot study. But let us be clear about what the study's findings suggest: up to 425,000 patients a year, over 1,000 patients a day, suffer an adverse event which is avoidable. How many lead to death we do not know, but, as we suggested in Chapter 21 it could be as high as 25,000 people a year. Full-scale studies in the United States [4] and in Australia [5] indicate that a similar incidence of error or mishap occurs in both of these countries. If the estimate for Britain is broadly accurate, and further work is urgently needed to establish the full extent of the problem, then we face a profoundly alarming state of affairs.

3 The issues which lie behind these figures are complex. Safety is a relative, not an absolute term. What constitutes safe care can change over time as known risks are better understood and managed, and new risks emerge with new procedures and forms of treatment. Furthermore, the extent to which a treatment or a procedure is safe, or risky, or unsafe can vary according to a patient's condition and state of health. Some procedures and treatments, such as open-heart surgery, are inherently risky, whatever the patient's condition. Others, such as the administration of aspirin or a routine injection, might on the face of it, appear to carry a low risk. Yet, if the wrong drug is inadvertently administered, or the wrong dose or concentration given to a patient, so narrow may be the margin of safety that the consequences can be catastrophic.

Footnotes

[2] We take the term `adverse event' to mean the occurrence of an untoward and an unplanned event which results in harm to a patient

[3] Vincent C, Neale G, Woloshynowych M. `Adverse Events in British Hospitals: Preliminary Retrospective Record Review'. `BMJ' 2001; 322: 517-19. www.bmj.com

[4] Brennan TA, et al. `Incidence of Adverse Events and Negligence in Hospitalised Patients. Results of the Havard Medical Practice study I'. `New England Journal of Medicine' 1991; 324: 370-6

[5] Wilson RM, et al. `The Quality in Australia Healthcare Study'. `Med J Aust' 1995; 163: 458-71