The NHS must learn from its mistakes

In the final yr, there have been 123 situations in which swabs, instruments or other products have been left within sufferers following surgery. Photograph: Rex Characteristics

Maurice Murphy died soon after a nasogastric tube was passed through his nose into his lung alternatively of into his stomach. Murphy, the principal trumpet of the London Symphony Orchestra for 30 years, was being handled in an NHS hospital in London for a liver complaint. A junior nurse who queried regardless of whether the tube was in the correct spot was told by the doctor in charge: “You don’t have the brain to keep in mind that I advised you to start off the feed. The tube is in the right place.”

Murphy, who died in 2011, was a victim of a “never event” – mistakes so referred to as since they must never ever occur. His case was recalled by Prof Sir Liam Donaldson, former chief health care officer, who advised a group of NHS experts this month that never occasions do still occur – at the rate of 300 a yr in England. They incorporate (from final 12 months) a female who had her fallopian tube eliminated rather of her appendix and 123 cases in which swabs, instruments or other products had been left within sufferers soon after surgical procedure.

What sufferers want, following incidents like these, is that the NHS understand from its blunders. However, to consider just a single example, the misplacement of nasogastric tubes continues. There were twenty reported circumstances in 2012-13 and 14 in 2013-14. These are lower numbers in the context of the millions of sufferers treated in the NHS each and every year. But they are unacceptable and in any other sector its leaders would be saying we will not want any errors of this variety.

Last year Prof Nick Black of the London School of Hygiene and Tropical Medication and I had been asked by Sir Bruce Keogh, healthcare director of NHS England, to investigate 14 NHS trusts that were offering concern due to the fact they had large mortality costs. There are several attainable reasons for a substantial hospital mortality rate, like a shortage of hospice beds in an area (which indicates patients die in hospital when they could have been transferred to die in a hospice which specialises in the care of terminally sick sufferers). Our brief was to examine what proportion of the deaths in these trusts was avoidable due to poor care, and whether or not there was a link with the higher total death fee.

We are comparing the level of avoidable deaths in the 14 trusts with 10 matched trusts with reduced mortality charges and anticipate to report back to Keogh at the finish of this 12 months or early in 2015.

In addition, the Institute of Worldwide Wellness Innovation based mostly at Imperial University London, which I lead, is studying far better methods of collecting and disseminating information on patient security incidents in the NHS. Close to 1.2m incidents are being voluntarily reported each yr in the NHS, the huge vast majority of which cause no or lower harm – but they give a enormous understanding opportunity which will grow as far more reports are produced.

This perform will contribute to the patient safety drive announced by Jeremy Hunt final month with a target of halving deaths from avoidable harm which it is hoped will save six,000 lives over three many years. The measures the overall health secretary announced incorporated a duty of candour on the NHS to be open with individuals about mistakes and the appointment of 5,000 safety champions charged with identifying unsafe care.

In addition to these initiatives, there are two new developments that should make care in Britain’s hospitals safer.

1st, 15 expert groups, called patient security collaboratives, are to be created, covering every single region of the nation to share very best practice.

Secondly, from following April, all NHS trusts will be mandated to investigate deaths in their hospitals in a standardised way by specially trained consultants who will be needed to judge what proportion had a dilemma with their care and were avoidable.

These investigations will be subject to independent review by a central panel of trained medical doctors who will supply a national snapshot of the degree of avoidable deaths in our hospitals. This will be of apparent interest to our political leaders who will want to see the proportion coming down.

A key concern is no matter whether we use safety incident reports for understanding or for overall performance management. I favour learning. 1 of the ideal ways to find out is from other’s innovations. But we need to uncover greater methods to spread knowledge. It has been known for years that a easy way to get rid of naso-gastric mistakes is to use ph indicator paper to check the fluid aspirated by way of the tube. But the message has not spread. To share that information and assist trusts across the nation drive out avoidable errors like the one particular that killed Maurice Murphy would be a fitting memorial to the London Symphony’s trumpeter.

Lord Darzi is a surgeon and director of the Institute of Worldwide Well being Innovation. He was a Labour health minister from 2007-09

This report is published by Guardian Professional. Join the Healthcare Pros Network to acquire regular emails and unique provides.

The NHS must learn from its mistakes