The Patient Safety Collaborative

Making a difference - Prevention Systems for Patient Safety

The Rise of Patient Safety as an Issue

“Medicine has always put patients at risk. Modern medicine raises the stakes as its power to do good is accompanied by increasing potential for harm. Only now is the medical world waking up to the importance of ensuring patient safety.”
Wilson T’, Pringle M, Sheikh A - Promoting Patient Safety in Primary Care. BMJ 2001;323:583-584

Experiencing harm as a result of receiving health care is a growing concern for the public. Front-page articles in newspapers, television exposes, and cover stories in magazines have provided the stark details of the latest and most dramatic examples of medical errors. Two high profile government reports “To err is human. Building a Safer Health System” (USA, 1999, Institutes of Medicine), and “Organisation with a Memory”, (UK, June 2000, Department of Health) both tackled the issues of medical errors and patient safety in their respective countries and served to fuel the debate and level of concern.

The size of the problem is enormous. The IOM report estimates that medical errors cause between 44,000 and 98,000 deaths annually in the United States. Using the more conservative figure, medical errors rank as the eighth leading cause of death, killing more Americans than motor vehicle accidents, breast cancer, or AIDS. In addition to this extraordinary human toll, medical errors result in annual costs of $17 to $29 billion in the United States.

Comparable data from the UK shows a similar picture - suggesting that rates in excess of 850,000 patients, or 10% of admissions to UK hospitals, are caused by adverse events. The cost of these errors in financial terms is escalating, both in terms of direct costs to the healthcare system and indirect costs to the nation as a whole, in the form of ongoing disability and other benefits. Estimates of some of the costs to the NHS, and subsequently the taxpayer, are:

1. Up to £2 billion annual direct costs of additional bed days caused by adverse events; and
2. A £2.6 billion bill for medical negligence claims, plus a further estimated bill of £1.3bn relating to negligent episodes that are likely to have occurred but for which claims have not yet been filed (BMJ 2001;322:1081).

In addition, there is a great human cost to consider - patients may experience pain, disability, additional treatment and a variety of psychological disorders, such as depression and post traumatic stress disorder. Their personal and family relationships, their social and working lives may be profoundly affected. Additionally, fear of becoming a victim of medical error may lead patients to delay obtaining potentially beneficial medical care, which may allow their illnesses to worsen.
There is also the healthcare professional to consider, who may experience shame, guilt and distress after an adverse event, leading to a reduction in efficiency and confidence. Such feelings may well be exacerbated if a complaint is made, especially if such a complaint leads to litigation and/or disciplinary action being taken.

When the political pressure on governments to act is added to the financial and other pressures, it is clear that action must be taken. Therefore, in the UK, the National Patient Safety Agency was established as a special Health Authority on 2 July 2001 to provide a catalyst for change. The Patient Safety Collaborative will aim to establishing reporting systems, feedback loops and learning processes that meet both the unique demands of Primary Care and the needs of the NPSA