Why patient safety is important...

  • Because people die or get injured needlessly, including healthy people undergoing ‘routine’ operations (MB video on Elaine)
  • The number of people who die as a result of unsafe care is equivalent to 9 medium size aircraft (Boeing 737/Airbus A320) being written off with total loss of life every year in the UK
  • Most errors are identifiable and avoidable
  • Often non-clinical human factors (e.g. poor communication, not following protocols) are key elements in care failure
  • Failures in care affect the reputation of the NHS

o“We were the first hospital burned by the first Doctor Foster report and were labelled the hospital you were most likely to die in. It came as a surprise as we were a three star trust. We were vilified in the press. The Sun ran a cartoon saying ‘Good news: you’re having your op tomorrow. Bad news: you’re having it in Walsall.’ Deaneries tried to pull out of the trust. It rocked local confidence in the service.” - Dr Mike Browne (Medical Director & Director of Infection Prevention and Control at Walsall Hospitals NHS Trust)

  • Failures in care affect staff morale
  • After a recent inquest following the death of a patient in Cwm Taf Health Board, the Medical Director said the following: “On the penultimate day of the inquest, a member of the radiography team burst into tears, saying that they felt “ashamed” at what had happened. That’s what I felt too; shame”.
  • Failure costs money – harming patients means they have to stay longer in hospital, require extra treatment and tests, and need more follow-up care.
  • At Preventing Pressure Ulcers we were told that a study was done on one patient in Ireland who developed a bed sore and their treatment ended up costing over £100,000. (One patient!)
  • The increase in length of stay in critical care as a result of CLI was an average of 17.81 days per patient. The cost of a bed in ITU works out at £1,596 per day. CLI also resulted in additional drugs being prescribed, and necessitated tests being run, with additional costs averaging at £105.19 for drugs and £27.99 for tests. The total average cost of a patient developing a CLI in ITU was thus calculated at £28,563.81. (research done at Cardiff and Vale)
  • Failures also carry a large monetary cost in terms of compensation and litigation
  • See clipping – Great Western Hospital NHS Trust had to pay out £100,000 for what was described as “systematic deficiency”
  • *The future liabilities to NHS Wales have risen from £254.2m in 05/06 to £296.3m in 08/09 (these are payments which are spread over the claimants lifetime and need to be accounted for year-on-year)
  • *At the end of 2009 there are 1,650 open claims against the NHS, a year-on-year increase of 300
  • *There are about 5 claims per day
  • *The majority of claims are below £25,000
  • *All claims below £25,000 are paid by the relevant LHB
  • *65-70% of the value of pay outs are in maternity cases, which make up a very small number of the total claims made
  • [All *asterisked bullet points are figures from the Welsh Risk Pool and Welsh Health Legal Services]
  • Often failures in care are the result of poor processes not poor performance
  • Many lapses in care could be avoided
  • Processes can be changed to mitigate against error, so they should be changed
  • Safer processes are more productive processes (MB video on this subject)