Our hospitals disclose 11,000 patient safety incidents

Outside Lister Hospital in Stevenage

Patient safety incidents recorded by the East and North Hertfordshire NHS Trust in 2020/21 include three 'never events' - Credit: East and North Hertfordshire NHS Trust

More than 11,000 patient safety incidents were reported by the East and North Hertfordshire NHS Trust in 2020/21, including wrong site surgery and accidental connection to the wrong medical gas.

Between April 1, 2020 and March 31, 2021, the NHS trust which runs Stevenage's Lister Hospital and Welwyn Garden City's New QEII Hospital reported 11,876 patient safety incidents - an average of 989 per month.

Patient safety incidents are defined by the NHS as any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare.

Of the incidents reported by the East and North Herts NHS Trust, 11,531 - 97 per cent - resulted in no or minimum harm and 59 were deemed serious. The serious incidents included 14 related to care, five related to safeguarding, four to resuscitation and four to diagnosis. There were also three related to treatment, two related to infection control, one to anaesthesia and one to surgery.

Three 'never events' - which can cause serious harm or even death and are deemed by the NHS to be largely preventable - were also reported by the NHS trust in 2020/21. In September, oxygen tubing was accidentally connected to an air flow meter, and in October and December wrong site surgery took place. All three incidents resulted in minimum harm.

A report to the NHS trust's board says: "Learning identified changes in staffing led to poor compliance with medical gas safety checks to reliably remove air outlet equipment from bed spaces. This has led to pharmacy-led improvements to improve safety checks and communicate learning from this incident.

"The trust has established a Safer Surgery Collaborative, where clinical teams are supported to safely adopt local plans National Safety Standard for Invasive Procedures."

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Also recorded in 2020/21 were 652 inpatient falls - a 12.72 reduction compared to 2019/20 - and 235 preventable hospital-acquired pressure ulcers, which is a 55 per cent increase from the previous year.

The report to the board says: "It is likely this is partly related to the COVID-19 pandemic, with 30 per cent of pressure ulcers reported directly affecting patients diagnosed as COVID positive.

"Every hospital-acquired pressure ulcer is investigated by a tissue viability nurse to enable identification of gaps in care so learning can be identified and improvements delivered."

Martin Armstrong, the NHS trust's deputy chief executive, said: “We’re pleased our staff feel comfortable reporting patient safety incidents, particularly where there was no harm, but where they identified a potential risk.

"Through an open culture where staff and patients are able to speak up, we continue to improve the quality of care we provide.”

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