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Patient safety in Wales 'at risk' over alerts, warns charity Patient safety in Wales 'at risk' over alerts, warns charity
(35 minutes later)
Patients in Wales are at unnecessary risk and some may have died because the NHS is failing to respond quickly enough to UK-wide alerts on patient safety, said a charity. Patients in Wales are at unnecessary risk and some may have died because the NHS is failing to respond quickly enough to UK-wide alerts on patient safety, a charity says.
Action Against Medical Accidents said none of Wales' seven health boards hit deadlines to comply with all alerts.Action Against Medical Accidents said none of Wales' seven health boards hit deadlines to comply with all alerts.
It reported significant improvement in compliance but had concerns about two of Wales' health boards.It reported significant improvement in compliance but had concerns about two of Wales' health boards.
The Welsh government said it took patient safety very seriously.The Welsh government said it took patient safety very seriously.
Patient safety alerts are issued across the UK when things have gone wrong repeatedly in the NHS causing harm or even death.Patient safety alerts are issued across the UK when things have gone wrong repeatedly in the NHS causing harm or even death.
Alerts issued by the National Patient Safety Agency, a UK health watchdog, include:Alerts issued by the National Patient Safety Agency, a UK health watchdog, include:
Each alert has a deadline for its implementation.Each alert has a deadline for its implementation.
The total number of alerts outstanding across Wales reduced from 140 to 61 during the past year - a drop of almost 60%.The total number of alerts outstanding across Wales reduced from 140 to 61 during the past year - a drop of almost 60%.
Every health board has seen an improvement in their rates.
However, Action Against Medical Accidents found some of Wales' health boards had not fully complied with certain alerts even though the deadline for implementation was more than five years ago.However, Action Against Medical Accidents found some of Wales' health boards had not fully complied with certain alerts even though the deadline for implementation was more than five years ago.
The worst rate of compliance was at Hywel Dda Local Health Board, covering Carmarthenshire, Ceredigion and Pembrokeshire, which had not fully implemented 23 of the alerts by the deadlines.The worst rate of compliance was at Hywel Dda Local Health Board, covering Carmarthenshire, Ceredigion and Pembrokeshire, which had not fully implemented 23 of the alerts by the deadlines.
In response, a spokesman said: "Hywel Dda Health Board takes compliance with patient safety alerts very seriously and has undertaken a review of accountability and responsibility to improve its response.In response, a spokesman said: "Hywel Dda Health Board takes compliance with patient safety alerts very seriously and has undertaken a review of accountability and responsibility to improve its response.
"As a relatively new organisation we also made the decision to review and revalidate compliance against patient safety alerts dating back to 2002 and believe this good practice will place us in a confident position in terms of compliance moving forward."As a relatively new organisation we also made the decision to review and revalidate compliance against patient safety alerts dating back to 2002 and believe this good practice will place us in a confident position in terms of compliance moving forward.
"We'd wish to assure our patients that compliance is closely monitored and reported to the health board's quality and safety committee.""We'd wish to assure our patients that compliance is closely monitored and reported to the health board's quality and safety committee."
The report said the performance of Betsi Cadwaldr University Health Board, which runs health and hospital services across north Wales, was "also of particular concern", with 23 alerts outstanding past their deadlines. The report said the performance of Betsi Cadwaldr University Health Board, which runs health and hospital services across north Wales, was "also of particular concern", with 15 alerts outstanding past their deadlines.
Betsi Cadwaldr health board told BBC Wales that it would be inappropriate to comment until it had seen and considered the report in full.Betsi Cadwaldr health board told BBC Wales that it would be inappropriate to comment until it had seen and considered the report in full.
Two health boards, Abertawe Bro Morgannwg (which covers Swansea, Bridgend and Neath Port Talbot) and Aneurin Bevan (which is responsible for the former Gwent area), reduced the number of outstanding alerts to just four each, the report found.Two health boards, Abertawe Bro Morgannwg (which covers Swansea, Bridgend and Neath Port Talbot) and Aneurin Bevan (which is responsible for the former Gwent area), reduced the number of outstanding alerts to just four each, the report found.
It concluded: "Whilst there has been significant and welcome improvement in compliance with patient safety alerts, it is very concerning that Hywel Dda and Betsi Cadwaldr health boards still have so many alerts outstanding, some of which are years past the deadline for completion, and that no single health board is fully compliant.It concluded: "Whilst there has been significant and welcome improvement in compliance with patient safety alerts, it is very concerning that Hywel Dda and Betsi Cadwaldr health boards still have so many alerts outstanding, some of which are years past the deadline for completion, and that no single health board is fully compliant.
"According to Standards for Health Services in Wales there should be 100% compliance. Patients are being left at unnecessary risk."According to Standards for Health Services in Wales there should be 100% compliance. Patients are being left at unnecessary risk.
"It is possible that some patients may have suffered harm or even died needlessly as a result of alerts not being complied with.""It is possible that some patients may have suffered harm or even died needlessly as a result of alerts not being complied with."
The report suggests two health boards - Aneurin Bevan and Betsi Cadwaladr - have failed to fully implement procedures designed to reduce the risk of giving patients the wrong blood transfusion, despite the deadline for its implementation passing in May 2007.The report suggests two health boards - Aneurin Bevan and Betsi Cadwaladr - have failed to fully implement procedures designed to reduce the risk of giving patients the wrong blood transfusion, despite the deadline for its implementation passing in May 2007.
Only three boards - Cardiff and Vale, Cwm Taf (covering the south east Wales valleys) and Powys - had completed actions on an alert designed to improve the safe administration of oxygen.Only three boards - Cardiff and Vale, Cwm Taf (covering the south east Wales valleys) and Powys - had completed actions on an alert designed to improve the safe administration of oxygen.
The deadline for completion of this alert was March 2010.The deadline for completion of this alert was March 2010.
And three health boards - Aneurin Bevan, Cwm Taf and Hywel Dda - had yet to complete actions to prevent deaths from giving patients an incorrect dose of medicines, missing its November 2011 deadline.And three health boards - Aneurin Bevan, Cwm Taf and Hywel Dda - had yet to complete actions to prevent deaths from giving patients an incorrect dose of medicines, missing its November 2011 deadline.
Action Against Medical Accidents has called for an urgent review in the way patient safety is regulated in Wales.Action Against Medical Accidents has called for an urgent review in the way patient safety is regulated in Wales.
It claims Health Inspectorate Wales (HIW) could not provide it with evidence that it had taken action to ensure compliance with patient safety alerts.It claims Health Inspectorate Wales (HIW) could not provide it with evidence that it had taken action to ensure compliance with patient safety alerts.
It said: "Health Inspectorate Wales appears to have ignored our previous reports and failed to protect patients' safety by ensuring patient safety alerts are complied with.It said: "Health Inspectorate Wales appears to have ignored our previous reports and failed to protect patients' safety by ensuring patient safety alerts are complied with.
"This is a serious dereliction of duty.""This is a serious dereliction of duty."
HIW said it took alerts into account alongside a range of other intelligence when preparing to inspect or review NHS bodies.HIW said it took alerts into account alongside a range of other intelligence when preparing to inspect or review NHS bodies.
The report also accused HIW and the Welsh government of failing to take the issue of non-compliance seriously and said the health minister had refused a meeting to discuss the issues.The report also accused HIW and the Welsh government of failing to take the issue of non-compliance seriously and said the health minister had refused a meeting to discuss the issues.
A Welsh government spokesperson said: "We welcome scrutiny of patient safety - this is a matter we take very seriously.A Welsh government spokesperson said: "We welcome scrutiny of patient safety - this is a matter we take very seriously.
"While it is encouraging that NHS organisations have made major improvements to compliance on patient safety alerts, more still needs to be done to achieve full compliance."While it is encouraging that NHS organisations have made major improvements to compliance on patient safety alerts, more still needs to be done to achieve full compliance.
"We continue to monitor this data across health boards and have set up a group to look at particular areas of concern."We continue to monitor this data across health boards and have set up a group to look at particular areas of concern.
"We have made it clear we expect all organisations to make further improvements in the interests of patient safety and quality of services.""We have made it clear we expect all organisations to make further improvements in the interests of patient safety and quality of services."