A new report published this month in the Journal of the Royal Society of Medicine, has identified 377 incidents of severe harm or death in acute care settings in England and Wales over a 10-year period, with most resulting from diagnostic, medication or monitoring errors.
Delays in diagnosis were the most frequent diagnostic error, with cancer misdiagnosis the most common. This is particularly worrying considering the huge increase in NHS waiting lists caused by the pandemic and the pressure on NHS resources. Almost a third of the 79 diagnostic errors resulted in the patient dying and a quarter receiving delayed treatment.
According to the results from the 10-year national study, patient safety incidents occur in 6% of all patient cases acutely admitted to hospital and of those, 12% result in severe or fatal outcomes. Acutely sick patients are at heightened risk of unsafe care during handovers and transfers of care, the report notes.
Staff mistakes and medication chart errors
There are many possible causes, however the study identifies that diagnostic errors are often the result of routine investigations; either because of incorrect interpretation of the results or incorrect response. Equally, the tests are conducted without understanding the effects on patient’s care.
The evidence from a previous study suggests that a lack of attention leads to signs of alternative diagnoses being missed. Staff mistakes were shown to be the most frequent cause of diagnostic errors, with misinterpreting investigations being the most common error.
A separate study from the same team revealed that 46% of the medication charts investigated contained errors, mostly the omission of medication.
“This new report makes worrying reading for acute patients and their loved ones,” said Carmel Walsh, an experienced medical negligence solicitor and Partner at York-based firm, Pryers Solicitors. “While we all understand how stretched NHS resources are right now, the solutions and recommendations made by the authors of this report are eminently sensible and should be in place already.”
The report concludes that the introduction of electronic prescribing and monitoring systems, checklists to reduce diagnostic errors and increased senior staff presence in the evenings and weekends, would all contribute to improved acute patient safety.