Every year thousands of patients in Scottish hospitals and GP surgeries suffer what is known as an adverse event - something that happens which should not, that may cause harm to the patient.
Up to one in 10 hospital admissions experience an adverse event, ranging from mistakes with drugs, to avoidable infection, injuries from falls and sometimes even unnecessary death. Moreover, more than one in 20 emergency admissions to hospital is caused by an adverse event related to medicines prescribed in primary care.
Half of these events are avoidable and are caused by a wide range of circumstances such as patients being misdiagnosed; being given the wrong drug or dosage; miscommunication and misunderstanding between healthcare professionals; and, on occasion, patients being wrongly identified.
While the human costs are paramount, these events also result in significant costs to the Scottish health service.
Now the Scottish Funding Council has given £1.5 M towards the creation of a new Scottish Patient Safety Research Network, which will strive to improve the situation. In addition, three universities are also pumping £1 million into the new initiative.
Led by Professor Rhona Flin of the University of Aberdeen, in collaboration with Professor Huw Davies of the University of St Andrews and Professor Peter Davey of the University of Dundee, the network will involve multidisciplinary research teams from the three centres studying adverse events in the Scottish healthcare system and examining both organisational and professional methods of improving safety.
Professor Flin heads the University of Aberdeen's Aberdeen Patient Safety Research Group, which is researching a wide variety of patient safety issues. She said: "I'm very excited about the new Scottish Patient Safety Research Network which will work hard towards improving patient safety by enhancing our knowledge of adverse events.
"The collaboration brings together leading research expertise from Aberdeen, Dundee and St Andrews and will operate in alliance with other initiatives that have been set up recently to improve the safety of patients within the Scottish healthcare system."
Professor Davies, who is Professor of Health Care Policy and Management and Director of the Social Dimensions of Health Institute, a joint Institute between the Universities of Dundee and St Andrews, said: "We need to understand the organisational and professional contexts within which these unfortunate events occur so that we are better able to design safer systems."
Professor Davey, who is Professor of Pharmacoeconomics and Director of External Relations for the Health Informatics Centre, added: "In Scotland we have unique opportunities to improve patient safety through better use of information. At the Health Informatics Centre we are eager to share our resources with experts in human and organisational behaviour to transform the safety of healthcare in Scotland".
The first phase of the collaboration will focus on three main areas that relate to the Chief Medical Officer's three priority issues for patient safety – monitoring, systems and education. The studies will involve patients, doctors, nurses, pharmacists, other Allied Health Professionals, NHS managers and staff. Specific aims include:
· Determining the nature and prevalence of adverse events to patients in Scotland in both primary and secondary care
· Developing an automated reporting system for analysis of clusters and time trends relating to adverse incidents
· Investigating the organisational culture underpinning safe/unsafe health care environments, especially the role of governance and management
· Examining safety management strategies used in high risk industries in Scotland (e.g. oil and gas production, nuclear power) for possible application in health care
· Developing materials for training courses on patient safety