Final Report > Chapter 26: The Safety of Care > Creating a culture of safety > The extent of adverse events and near misses - the urgent need to establish a baseline

The extent of adverse events and near misses - the urgent need to establish a baseline

19 There is a pressing need for research into some of the central questions about the type and extent of adverse events and near misses in the NHS. We need to be able to answer such fundamental questions as: What is the current scale of adverse events and (to the extent that it can be discovered) near misses? How do they arise? Can they be classified? How can they be guarded against? The Australian and US studies are of value, but they are some years old, and relate to different systems of healthcare. There are almost certainly issues of specific relevance to the NHS which need to be identified. The study of British hospitals by Professor Vincent, while extremely important, is a pilot study. We believe that major studies of the NHS, along the lines of those undertaken in Australia and the US, must be carried out in the UK. Such studies would be an invaluable source of information against which to measure progress. They are an essential part of the task of developing a coherent approach to safeguarding patients. They should be made a priority. [22]

Footnotes

[22] We note in this respect the research proposals contained in `Building a Safer NHS for Patients', Department of Health. www.nhs.org.uk April 2001