National patient safety: the importance of auditability

The National patient safety incident reports (NaPSIRs) set out the number of patient safety incidents reported to the National Reporting and Learning System and describe national patterns and trends. The latest report, published in October 2022, details incidents reported from April 2021 to March 2022. The findings show that despite an increase in the total number of reported incidents, the number of incidents with the highest degree of harm decreased by 7.3%. The most significant increase was seen in the number of incidents that resulted in no harm, which could be a sign of an improvement in transparency when reporting incidents.

A total of 81,863 incidents reported were categorised as related to consent, communication and confidentiality – an increase of nearly 5,000 compared to the previous year’s report. A past review* found that most incidents reported in this category were related to communication, mainly between different teams within the hospital – notably between medical and nursing staff and between ICU teams and the rest of the hospital. 

Communicating effectively with various teams within a hospital can be a challenging task as it is often hard to identify who the right person to contact is and what the most appropriate way of reaching that person might be. One of Alertive’s partner Trusts analysed incidents reported within their organisation pre-Alertive implementation and found that nearly 70% of incidents cited communication as a contributing factor. This highlighted a need for a comprehensive communication system that enables communication as well as facilitates a deeper understanding of the issues that have occurred through the use of an audit trail.

“Historically, we know that the Trust was using a number of different ways of communicating Bleeps, dect phones, WhatsApp and Teams, and not always in the right way. What Alertive enables is a safe way that we can securely message patient information. What we are then able to do if there’s an investigation, for example, is acquire that full transcript of the conversation. So we’ve got much more evidence than we would’ve had previously.” 

– Emily Wells, CNIO, Norfolk and Norwich University Hospitals NHS Foundation Trust

A UK multicentre survey study** also found that communication problems are top of patients’ concerns about hospital care, with communication being the most frequently occurring (22%) factor in all patient-reported incidents. Therefore, addressing these issues can also help improve the patient experience.

Awareness of all incidents that occur within a hospital is crucial as it supports clinicians in learning about why patient safety incidents occur within their organisation, the service it provides, and what they can do to keep their patients safe from avoidable harm. A complete audit trail showing all communication and decisions throughout the patient journey helps increase accountability and visibility, allowing for informed service improvements – ultimately leading to better patient care and outcomes. 

*Thomas, A. N., Panchagnula, U., & Taylor, R. J. (2009). Review of patient safety incidents submitted from Critical Care Units in England & Wales to the UK National Patient Safety Agency*. Anaesthesia, 64(11), 1178–1185. https://doi.org/10.1111/j.1365-2044.2009.06065.x

**O’Hara, J. K., Reynolds, C., Moore, S., Armitage, G., Sheard, L., Marsh, C., Watt, I., Wright, J., & Lawton, R. (2018). What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study. BMJ Quality & Safety, 27(9), 673–682. https://doi.org/10.1136/bmjqs-2017-006974