Does making NHS organizations pay for mistakes improve patient safety?

Clin Risk 2009;15:24
doi:10.1258/cr.2008.080109
© 2009 Royal Society of Medicine Press

 

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AvMA Medical & Legal Journal


Peter Walsh, Chief Executive


AvMA


The NHS has chosen to run with the suggestion of Lord Darzi to use a list of so-called ‘never events’ to financially punish NHS organizations who allow incidents from the list to harm patients. The proposal has generated a lot of debate, with the inevitable questions being raised about whether taking money away from an organization is going to make it safer or simply make things worse. Another source of animated discussion has been what should be the events which really should never happen in healthcare but currently do.

The eight events chosen so far by the National Patient SafetyAgency (but on which it was consulting until the end of October2008) are: wrong-site surgery; retained instrument post operation;wrong route administration of chemotherapy; misplaced naso ororogastric tube not detected prior to use; inpatient suicideusing non-collapsible rails or while on one-to-one observations;absconding of transferred prisoners from medium or high securemental health services; in-hospital maternal death from postpartumhaemorrhage after elective Caesarean section; and IV administrationof concentrated potassium chloride. The concept is based onan American initiative: there is a list of 28 events. In England,it is proposed that eventually Primary Care Trusts do not payproviders for treatment involving a ‘never event’or the remedial treatment due to it.

Apparently, the evidence from America is that this approachhas been helpful in trying to eradicate these incidents. InEngland there is a cautious approach. According to the NationalPatient Safety Agency (NPSA) website, the list that is eventuallyagreed will be issued for guidance only to PCTs. The list willnot be used for withholding money until 2010–2011. Thatseems to make sense. This is a radically different approachfor the UK. However, it remains to be seen whether the approachlends itself to a publicly run system. The money will come fromthe same limited pot as opposed to eating into somebody’s profits.It can be argued that holding back the money will only makethe organization even less able to operate safely, or punishpatients by meaning that treatment is rationed to make up thegap. Enthusiasts for the new approach may counter-argue thatPCTs will be able to shift contracts and treatment to organizationswho do operate safely. Frankly, it is hard to see how this allwill work in practice and there is a danger in a whole new bureaucracybeing set up. However, there is something important in the ideawhich should not be discounted as yet another gimmick. Mostpeople would agree that, ideally, it should not take money tomotivate people to deliver safe care. However, we know thatfinancial performance and the fear of financial consequencesfor an organization can make a difference. It is no coincidencethat the organization that holds the ring in terms of risk managementstandards for the NHS is currently the NHS Litigation Authority.Litigation has much to do with getting patient safety to thelofty position it currently enjoys in NHS priorities. Does anyonereally think that if there had not been a massive increase inthe numbers of people successfully suing for clinical negligencein the 1990s, that patient safety would enjoy the priority itdoes today? The litigation bill is mentioned every time thereis a debate about patient safety.

There is also something very symbolic about the designationof ‘never events’. They really should never happen,because it is perfectly possible for organizations to act strategicallyto eliminate them. They are not purely down to individual actsof negligence or chance. Drawing attention to these events whichshould never happen but do can only help hammer home the messagethat organizations simply have to take action or run the riskof being held to account. Receiving publicity for being responsiblefor an organization which has allowed a ‘never event’to happen is likely to be more of an incentive than the financialpenalty. The principle that people are not rewarded for badtreatment is also powerful.

However, there is always the danger in setting targets or prioritiesthat people take their eye off the other issues which also needaddressing. It would be counter-productive if trusts began toclaim that the fact they had not experienced a ‘neverevent’ in the last year or two as an indicator that theyare a ‘safe’ organization. ‘Never events’are going to be part of the NHS approach to patient safety,like it or not. It is possible to argue for more and more incidentsto be added to the list, and my hope would be that this happens.However, even in the short term, AvMA would like to see thelist reflect a more balanced approach. We are glad to see mentalhealth issues included in the list. We agree with the otherincidents listed, which are all too familiar to us from thecases we have dealt with. However, most are about ‘hightech’ or highly specialized interventions, and both hospital-and doctor-centred. We would like to see things in the listwhich are more about the reality of day-to-day basic care forvulnerable groups such as the elderly. We have put forward thecase for stages 3 and 4 pressure ulcers acquired in NHS careto be included. This is a huge problem and affects the elderlyand vulnerable patients in particular and is not just abouthospital care. Perfectly avoidable pressure ulcers acquiredin NHS care can and do cause major harm and even death. Theyare included in the US list, and are possible to measure asanyone coming into care should have an existing ulcer identified.Their inclusion would help send the message that patient safetyis as much about basic standards of nursing care as it is aboutsurgery and interventions.

Does making NHS organizations pay for mistakes improve patient safety?
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This Article
Does making NHS organizations pay for mistakes improve patient safety?

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Does making NHS organizations pay for mistakes improve patient safety?
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Does making NHS organizations pay for mistakes improve patient safety?
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Does making NHS organizations pay for mistakes improve patient safety?

Articles by Walsh, P.
Does making NHS organizations pay for mistakes improve patient safety?
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Does making NHS organizations pay for mistakes improve patient safety?
Does making NHS organizations pay for mistakes improve patient safety?

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