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The National Patient Safety Agency
  1. T Stephenson
  1. Correspondence to:
    Prof. T Stephenson
    Professor of Child Health, Queen’s Medical Centre, Nottingham NG7 2UH, UK and Clinical Specialty Advisor to the NPSA, 4–8 Maple St, London W1T 5HD, UK;

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Assisting the NHS to identify and learn when things go wrong

The National Patient Safety Agency (NPSA) is a Special Health Authority formed in 2001 to improve patient safety in the NHS across England and Wales. Currently, it has a budget of just over £15 million. The NPSA was created following the publication of two key reports by the Chief Medical Officer, Professor Sir Liam Donaldson, An organisation with a memory1 and Building a safer NHS.2An organisation with a memory refers to the death of Wayne Jowett following an inadvertent intrathecal vincristine injection, the 23rd such incident reported worldwide (and the 14th in 15 years in the United Kingdom).3

A central tenet of the NPSA’s creation was that it should assist all those involved in healthcare to identify and learn when things go wrong. When patient safety incidents occurred in the past they may not have been reported locally because they were not seen as important, staff were too busy, patient harm was averted (often known as a prevented patient safety incident or “near miss”), or because of a fear of a blame and punish culture. We need to move from automatically blaming individual front-line staff3 to an understanding of the underlying factors in the system which are more often responsible for incidents.4 For too long, the system has blamed the individual and exhorted staff “to try harder” or “be more careful”. The vast majority of NHS staff work very hard and are very careful, but human error cannot be eradicated by such simplistic calls to arms. In other cases, lessons were learned locally but not disseminated nationally. To overcome this, all clinicians and NHS organisations need to have the safety of patients at the heart of their practice. Safety is not an …

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