What does the National Patient Safety Agency do National Patient Safety Agency What does the National Patient Safety Agency do - National-Patient-Safety-Agency -
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What does the National Patient Safety Agency do
Terms such as "adverse incident" and "sentinel event" are NHS-management-speak for "blunder". More specifically, the NPSA says it is interested in "any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS-funded care." The emphasis on things that could have led to harm is important: the NPSA has a stated interest in recording and learning the lessons of "near misses", so that it does not take a tragedy to improve patient safety.
The NPSA is in the process of developing its system for reporting incidents. It will be called the National Reporting and Learning System (NRLS). The NRLS will be anonymous, so that clinicians who have been involved in incidents can feel free to be honest about what has happened without fearing that they will be sacked or sued as a direct result. This is not to say that anyone who reports an incident to the NPSA buys themselves immunity from any consequences: naturally, the normal complaints and investigation procedures will apply if anyone chooses to follow the matter up. However, the NPSA themselves are not there to place blame; they say they are "interested in the 'how' and not the 'who'." The idea is that, by encouraging clinicians to report their blunders, lessons can be learned that will minimise the chance of the same thing happening again in the future.
On the basis of what it learns from the NRLS and other sources, the Agency is involved in promoting patient safety in NHS organisations. In serious cases, it issues "Patient Safety Alerts", which are distributed throughout the NHS, and give guidance on a specific clinical matter. For example, a key Patient Safety Alert has been issued relating to the use of a particular medication (potassium chloride) that has been involved in several accidental overdoses. The Alert gives guidance on how to store and administer potassium chloride, with a view to minimising the risk of a dangerous mistake.
Finally, the NPSA also runs ongoing information campaigns. One basic but significant example is its current "cleanyourhands" campaign, which encourages clinicians to be more rigorous when it comes to washing their hands (a simple way of minimising the spread of infections from patient to patient, but one at which doctors are notoriously bad).