Public service watchdog, the National Audit Office, has underlined the key role IT should play in improving patient safety not only in avoiding medication errors but in supporting audit and providing information to professionals.

An NAO report published today identifies medication errors, record documentation errors and communication failures as leading causes of incidents in which patient safety is jeopardised.

But the report, A Safer Place for Patients, says that the potential for appropriate use of IT to improve patient safety is already well established. It also points to research that shows around 50% of recorded patient safety incidents could have been avoided if the lessons of previous incidents had been learned.

According to figures cited in the report, there were 974,000 incidents and near misses reported 2004-5, excluding hospital infections, in NHS acute, ambulance and mental health trusts which treat over a million people a day .

The report notes that Connecting for Health (CfH), the agency charged with delivering the National Programme for IT (NPfIT), has asked the National Patient Safety Agency to help assure the programme’s specifications and ensure that patient safety is inherent throughout the system.

"In taking this forward the National Patient Safety Agency should ensure that Connecting for Health fully understands and builds on the lessons from the development and roll out of the National Reporting and Learning System."

The theme of embedding patient safety into systems is emphasised elsewhere in the report in sections on training for professionals and in the culture of trusts. So, too, is the notion of providing feedback from incidents and learning lessons from them.

Here, technology is seen as an important facilitator. The report says: “The National Care Record has significant potential to improve safety as lost or poorly completed records are a major contributory factor to patient safety incidents.

“Technology will also facilitate retrospective audits, improve access to guidance and reduce the risk of incorrect drug prescribing and dosages.”

The report says electronic patient records will enable trusts to quickly identify unreported incidents, monitor trends and promote learning through clinical audit.

While the report praises trusts generally for developing more open and fair systems for reporting incidents, it is critical of the current reporting system which requires trusts subsequently to report incidents to numerous national bodies.

“Wherever possible, incidents should only be reported once and, as trusts move towards electronic reporting, the Department [of Health] should explore the possibility of recommending a single entry point, for example, via the NPfIT.

“As a minimum, the department should consult with CfH, the NHS Health and Social Care Information Centre, the National Patient Safety Agency, the Medicines and Healthcare Products Regulatory Agency and the relevant signatories of the Healthcare Inspection Concordat to identify the scope to rationalise the number of entry points.”

David Flavell, managing director of drug-releated clinical decision support specialists, FirstDataBank Europe, told E-Health Insider: "The report states that a minimum of 2,000 (and actually nearer 34,000) people died as a result of hospital errors and accidents in 2004-05. Many of these were caused by errors at the point of prescribing or dispensing drugs.

"The real tragedy of these figures is that there are systems available here and now to prevent medication errors. There is no need for people to be dying when information technology is available to help clinicians make more informed decisions about which medication to prescribe safely. These systems have been in use in GP practice for many years and in those hospitals where they have been introduced, are demonstrating real benefits.


National Audit Office