Preventing the worst

Every day an estimated 100 people die in hospitals from avoidable medical errors. Another 1,000 people suffer moderate or long-term injuries. Medical researchers are familiar with these "adverse events". They were bravely set out four years ago by Sir Liam Donaldson, the chief medical officer, when he launched his campaign to turn the NHS from its defensive role - in which adverse events were seen as "one-offs" - to an open system of admitting mistakes and learning from them. Yet a survey of 1,000 senior NHS managers and clinicians released this week by the Health Foundation found 75% were still seriously underestimating the extent of avoidable mistakes.

All health systems in the developed world record adverse event rates of between 5% and 15%, with the UK reporting 10%. But thanks to Sir Liam, Britain has become a world leader in trying to reduce mistakes. The National Patient Safety Agency (NPSA), set up three years ago, is already identifying preventable errors with its developing national reporting system. Hospitals, for example, operated 27 different "crash" numbers that staff used to call for help at times of cardiac arrest. Now there is one NHS-wide number so that agency staff working in different hospitals are no longer confused. Drug companies, which currently only give guidance on adult doses, are being asked to provide guidance on children's doses too.

The challenge facing NHS leaders is how to make adverse event rates better known to health staff without creating fear. The latest report from the Health Foundation, which is investing £4m in a programme to improve hospital safety, sensibly suggests that patients can play a part. Hospitals are already exploring this option with doctors and nurses wearing badges, which encourage patients to "Ask me whether I have washed my hands". The NPSA believes it is going to take 10 years to create an open reporting culture. What gives them hope is that air traffic controllers have been using just such a system of reporting errors and "near misses" for years that has dramatically improved air safety.