The Healthcare Commission has said that early warning systems on patient safety incidents, which highlight key issues on quality of patient care, must be improved.

The findings come in the Healthcare Commission’s report on its first five years of operation, and says there are serious gaps in the information available from hospitals on patient safety.

It says that “reporting of incidents when safe care has been compromised remains poor in large parts of the system” and that this needs to be addressed by NHS trusts as an “urgent priority.”

In particular, the report says there needs to be a more robust approach to the reporting of serious untoward incidents and sharing these reports nationally.

In addition, the report identifies that there is little or no data on risks to the safety of patients, which are not recorded as incidents. These types of risks include the failure to diagnose or the late diagnosis of a condition.

It acknowledges that despite obtaining such data being a “major challenge,” important cases will go unanalysed and patients will continue to be put at risk if it is not rectified.

The report was published by the Healthcare Commission to reflect on the lessons it has learnt from its work in the past five years.

The Healthcare Commission 2004-2009 annual report comes immediately after the Commission reported major failings in the quality of patient care in its investigation into mortality rates at Mid-Staffordshire Hospital.

The Commission, which uses mortality outliers as one of the ways to identify concerns in patient care, says current NHS hospital alert systems “need to be built on” and advises that “extending the approach to emergency re-admissions of patients into hospitals” would be beneficial.

The Commission will be replaced by a new integrated regulator health, mental health and adult social care, the Care Quality Commission at the end of the month.

The report also states that the “mandatory requirements for information placed in the independent healthcare sector fall well short of what is required for people using services to make informed decisions” and will therefore make it difficult for the new regulator to be able to access risk.


Mid Staff death rates-poor care not poor data