GEN/THUR/01 IMPROVING PATIENT SAFETY: WHAT CAN WE LEARN FROM NATIONAL INCIDENT REPORTING?

¹T Stephenson, ²L Haines, ³J Wheway, ⁴N Modi. ¹University of Nottingham, Nottingham, UK; ²RCPCH, London, UK; ³National Patient Safety Agency, London, UK; ⁴Imperial College London, London, UK

A statutory requirement placed on the National Patient Safety Agency was to devise and implement a national reporting system for patient safety incidents. The commonest reported safety incidents for patients under 18 years are different from those for adults. Comparing the 33 446 reports from January to December 2006 for children with the 663 658 reports for adults, the relative rates for the eight commonest paediatric issues were: medication problem 19% v 9%; treatment/procedure problem 14% v 7%; patient accident 13% v 41%; access problem 9% v 8%; documentation problem 8% v 5%; clinical assessment 7% v 4%; consent issue 7% v 4%; device problem 6% v 3%. Although it is gratifying that children suffer fewer accidents in hospitals or other health facilities, the high rate of problems with medications is particularly worrying. Half of prescriptions for children and 90% of prescriptions for neonates are for drugs that have not been licensed for that use.¹

Patient safety incidents in neonatology accounted for more than 12% of incidents reported for children and young people in the National Reporting and Learning System. There were 645 881 births in England and Wales in 2005, *of which 42 500 (6.6%) were born between 22 and 36 weeks’ gestation. In 2006, the single most frequently reported neonatal safety incident was also medication error. Of the 13 320 reports (approximately 4000 from the under 18 years dataset and 9000 from the obstetrics dataset) April to March 2007 for neonatal incidents, the relative rates for the eight commonest paediatric issues were: medication problem 18%; treatment/procedure problem 16%; access problem 16%; infrastructure …