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Most hospital safety incidents caused by 'slips, trips and falls'

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More than 700 patients died as a result of a patient safety incident between October 2011 and March 2012, latest data reveals.

Excluding mental health services, 746 patients died and 3,188 suffered severe harm while receiving NHS care, according to data collected by the National Reporting and Learning Service.

This is down from 926 and 3,398, respectively, over the same period in the previous financial year – although much of this could have resulted from the movement of some community provision out of the NHS meaning they no longer report incidents to the NRLS.

The biggest cause of inpatient harm in acute trusts was slips, trips and falls – referred to as patient accidents – accounting for just over a quarter of incidents, followed by problems with treatment and procedures and medication errors.

Data suggest patients are more likely to be harmed at small acute hospitals or specialist acute hospitals, which had an average of 7.5 and 8.4 patient safety incidents per 100 admissions respectively.

This compares to 6.5 at medium acute trusts, 6.2 at large acute trusts and 6.9 at acute teaching hospitals.

Meanwhile, the number of deaths resulting from patient safety incidents in mental health more than doubled year on year from 397 to 806. Much of the increase is believed to have been driven by the introduction of a new requirement to report suicides, or apparent suicides, as patient safety incidents.

Overall patient safety incidents in mental health increased from 84,763 to 105,288. The biggest cause was patient accidents, followed by self-harm and disruptive or aggressive behaviour.

Among the 27 standalone NHS community providers, the biggest cause of incidents was also patient accidents, followed by implementation of care and ongoing monitoring and review. Just over 3% of incidents at community providers were due to infrastructure factors, such as staffing, compared to 6.2% in acute settings and 2.2% in mental health.

The RNLS was previously part of the National Patient Safety Agency but is now hosted by the new NHS Commissioning Board. Reporting incidents to the NRLS is voluntary except where they result in death or severe harm.

The commissioning board warns this means a higher level of incidents does not necessarily mean an organisation is less safe, but could be a sign of a good reporting culture.

Mike Durkin, its director of patient safety, said: “NHS organisations should use this data and review the tools, guidance and support available to them.”

Organisation level data can be viewed here. See below for the most commons types of patient safety incident, according to the NRLS data:

 

Patient safety incidents in acute trusts by cause (Oct 11- Mar 12)  
Type of incidentNumber%
Patient accident120,34125.59
Treatment/procedure59,66612.69
Medication53,23411.32
Implementation of care & ongoing monitoring/review46,8389.96
Access/admission36,9057.85
Documentation34,0797.25
Infrastructure (staffing, facilities etc)290926.19
All others284016.04
Clinical assessment261835.57
Consent17,8343.79
Medical device/equipment17,7653.78
Total470,338 
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