A state of emergency

PUBLISHED: 12:55 28 September 2006 | UPDATED: 10:57 06 May 2010

The most important aspect of combating healthcare-acquired infections is hand hygiene, says Noel Scanlon

The most important aspect of combating healthcare-acquired infections is hand hygiene, says Noel Scanlon

EIGHT people have died as a direct failure in patient safety at our hospitals. New figures for East and North Hertfordshire NHS Trust show more than 1,600 incidents occurred over the three-month period from January to March this year in which patients cou

EIGHT people have died as a direct failure in patient safety at our hospitals.

New figures for East and North Hertfordshire NHS Trust show more than 1,600 incidents occurred over the three-month period from January to March this year in which patients could have suffered harm.

In the most serious of cases eight people died and four were permanently harmed while receiving NHS-funded care at Lister, QEII and Hertford County hospitals.

Noel Scanlon, the Trust's director of nursing, claims the eight deaths occurred over a two-year period and not the three months stated in the official report issued by the National Patient Safety Agency.

He said: "I wish to reassure everyone that the coroner has been involved in all relevant cases and we have been absolutely open with patients and families where an investigation has been initiated.

"It is also important to stress that in each of the eight patient deaths it is the Trust's belief that any weakness or systematic failure that occurred did not cause the death, but may have contributed to it.

"While often occurring in the saddest of cases, it is a tribute to our staff that they feel confident to report such incidents in the knowledge that the Trust will investigate them fairly and not seek to attribute blame where none exists."

But the report shows for every 100 admissions at the Lister, QEII and Hertford County hospitals, an average of 8.3 patients reported a patient safety incident - the fourth highest in a group of 45 similar NHS organisations in England and Wales.

And 16 per cent of reported incidents regarded errors in medication, compared with 7.9 per cent across the 45 organisations.

Almost half (43.8 per cent) of these mistakes were made at the administration stage of a medicine and 38 per cent at the prescription stage.

Mr Scanlon said: "Adverse incidents happen in every NHS Trust.

"Due to the complexity of healthcare and the hundreds of thousands of decisions and actions taken by staff every day, mistakes are inevitable.

"What the Trust has done over the last few years is to create a culture where staff feel confident to report even the smallest error, so that the information can be captured and lessons learnt that ultimately benefit everyone.

"This Trust has a high level of incident reporting, especially those minor mistakes that cause little, or no, harm to patients.

"It would be all too easy to characterise this sensationally and thus undermine confidence of patients in the care they receive.

"All experts concur, however, that high levels of reporting represents an open learning culture that ultimately results in higher safety standards and better treatment.

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