Step 54: National Patient Safety Agency

Abstract

The National Patient Safety Agency (NPSA) was set up in July 2001 following the report An Organization with a Memory (Department of Health (DoH), 2000). This report recommended that the NHS would benefit from the aircraft business and the fact that lessons were learnt from every untoward incident. The report recommended that the DoH should examine the feasibility of setting specific targets for the NHS to achieve in reducing the levels of frequently reported incidents. For example it was suggested that by 2005 the number of instances of negligent harm in the field of obstetrics and gynaecology which result in litigation should be reduced by 25% (these cases currently account for around half the annual NHS litigation bill). Following the report An Organization with a Memory, the DoH's (2001a) published Building a Safer NHS for Patients which set out details of a scheme for national reporting of adverse incidents, together with recommendations for an improved system for handling investigations and inquiries across the NHS. Subsequently in July 2001 the NPSA was set up with the aim that there would be a mandatory reporting system for logging all failures, mistakes, errors and near misses across the health services (DoH, 2001b).