NHS Patient Safety Timeline

Guidance to hospitals on the prevention of surgical accidents (HM(72)37)

Guidance to hospitals on the reporting of accidents associated with defects in medicinal products, supplies and equipment (HM(73)9).

Report of the Davies Committee into hospital complaints procedures (Report of the Committee on Hospital Complaint Procedure).

Establishment of the Health Service Commissioner (Ombudsman). Patient complaints can be referred to the Ombudsman, but it is not empowered to investigate clinical complaints, or the actions of GPs.

Hospital Complaints Procedure Act requires that all NHS hospitals have a complaints procedure in place.

Establishment of NHS Management Executive.

Report of Audit Commission finding continuing problems with NHS complaints procedure.

Directorate of Public Health in North Thames (West) Region funding programme of research into complaints, claims and risk management.

Publication of Risk Management in the NHS by the NHS Management Executive. This manual, aimed at managers within the NHS, covered direct and indirect risks to patient care, health and safety risks, and organisational risks such as data security. Sir Duncan Nichol, the Chief Executive of the NHS Management Executive, warned health care providers that 'risk management ... is no longer an optional extra'. Amongst its many recommendations was the need for NHS providers to establish standardised incident reporting systems, and the need for training of staff in risk management.

Health Service Commissioner (Ombudsman) required to consider clinical complaints and actions of GPs.

Regional Health Authorities (RHAs) abolished, replaced by regional offices of the NHS Executive; District Health Authorities replaced by Health Authorities.

Annenberg I conference on patient safety (‘Examining Error in Medicine’) at the Annenberg Center

NHS Trusts begin to publish death rates from surgery

(October) Opening of the public inquiry into the events at Bristol Royal Infirmary (Kennedy Inquiry)

Health Select Committee considers the handling of adverse incidents and occurrences in the NHS.

Department of Health commissions Expert Committee on Learning from Experience under the chairmanship of Chief Medical Officer, Liam Donaldson.

Trusts required to publish annual reports on clinical governance.

Development of the London Protocol – a framework for the investigation of clinical incidents

US Institute of Medicine report To Err is Human: Building a Safer Health System.

Health Act: Creation of Primacy Care Trusts (PCTs); statutory duty on PCTs, Health Authorities and NHS Trusts to monitor and improve quality; Commission for Health Improvement.

Establishment of National Institute of Clinical Excellence (NICE)

Publication of consultation paper Supporting Doctors, Protecting Patients.

Department of Health report Building a Safer NHS for Patients: Implementing An Organisation With A Memory sets out the steps taken by the government to fulfil the recommendations of An Organisation with a Memory. This includes the rationale behind the creation of the National Patient Safety Agency (NPSA) and the new, mandatory National Reporting and Learning System (NRLS).

Establishment of National Patient Safety Agency (NPSA).

Establishment of Commission for Health Improvement (CHI).

Publication of Kennedy Report into children's heart surgery at Bristol Royal Infirmary.

Establishment of the Shipman Inquiry.

Journal Quality in Health Care becomes Quality and Safety in Health Care

World Health Organisation resolution on patient safety

NPSA Conference, Building a Patient Safety Culture.

NPSA releases first patient safety alert, on preventing accidental overdose of intravenous potassium.

Strategic Executive Information System (STEIS) made available to all NHS organisations. The system is used to capture managerial information, for example daily situation reports (SITREPs) and serious adverse incidents.

National Health Service Reform and Health Care Professionals Act; renaming and replacement of Health Authorities with Strategic Health Authorities (initially 28, later reduced to 10); abolition of NHS Executive and its regional offices.

Establishment of Commission for Patient and Public Involvement in Health

Establishment of Council for Healthcare Regulatory Excellence (CHRE)

Establishment of Patient Advisory and Liaison Services (PALS)

Consultation paper Making Amends, setting out proposals to reform system of clinical governance and recommending a legal duty of candour.

Establishment of National Reporting and Learning System (NRLS)

Establishment of Medicines and Healthcare Products Regulatory Agency (MHRA), merging the Medicines Control Agency and Medical Devices Agency.
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Design Council/Department of Health report, Design for Patient Safety: A System-Wide Design-Led Approach to Tackling Patient Safety in the NHS.

Creation of Council for Healthcare Regulatory Excellence (CHRE).

Publication of NPSA patient safety guidance, Seven Steps to Patient Safety.

Health Foundation launches the Safer Patients Initiative (ran until 2008).

Department of Health report Building a Safer NHS for Patients: Improving Medication Safety

Formation of the World Alliance for Patient Safety.

National Audit Office report: A Safer Place for Patients: Leaning to Improve Patient Safety

NPSA alert and guidance on Being Open: Communicating Patient Safety Incidents with Patients and their Carers

Publication of Healthcare Risk Assessment Made Easy by NPSA

Concerns raised about mortality rate at Mid Staffordshire General Hospitals NHS Trust

Publication of Lord Darzi’s review, High Quality Care for All.

Corporate Manslaughter and Corporate Homicide Act.

Launch of Patient Safety First Campaign by NPSA, NHS Institute for Innovation and Improvement, and the Health Foundation.

UK trials, and a year later fully implements, WHO surgical checklists.

Mid Staffordshire General Hospitals NHS Trust attains Foundation Trust status (January). Healthcare Commission launches investigation into Mid Stafforshire NHS Foundation Trust (April).

Formation of Safe Anaesthesia Liaison Group. A collaboration between the Royal College of Anaesthetists, Association of Anaesthetists and NHS England

Establishment of the Care Quality Commission (CQC), replacing the Healthcare Commission.

Establishment of the National Quality Board.

NHS providers publish annual quality accounts, including patient safety.

The NHS Constitution published, embodying a commitment to patient safety as both an underlying principle and a right.

Non-statutory inquiry into the events at Mid Staffordshire NHS Foundation Trust commissioned by Secretary of State for Health, Andy Burnham. Chaired by Robert Francis QC (published in 2010).

WHO Surgical Safety Checklist mandated for use in NHS

NPSA revised guidance on Being Open

NPSA publishes first iteration of its Never Events Policy Framework. 'Never events' are defined as 'serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.' Initially, eight never events are listed including wrong-site surgery and retained instrument post-operation. The term 'Never Event' was first introduced in 2001 by Ken Kizer, the former CEO of the National Quality Forum in the USA.

Publication of initial Francis Report into healthcare failures at Mid Staffordshire NHS Foundation Trust.

Public inquiry into events at Mid Staffordshire NHS Foundation Trust announced by Secretary of State for Health, Andrew Lansley. Again chaired by Robert Francis QC (Final report published in 2013).

NPSA publishes National Framework for Reporting and Learning from Serious Incidents Requiring Investigation (the Serious Incident Framework). The SIF was revised by the NHS Commissioning Board in 2013, and again by NHS England in 2015.

Commencement of National Venous Thromboembolism (VTE) Prevention Programme, mandating risk assessment for VTE for all adult inpatients to acute hospitals in England.

NPSA. Functions transferred to NHS England.

CHRE becomes Professional Standards Authority for Health and Social Care (PSA).

Full Francis Report on healthcare failures at Mid Staffordshire NHS Foundation Trust.

Berwick Review into patient safety: A Promise to Act—A Commitment to Learn.

Designation of Academic Health Science Networks (AHSNs)

Establishment of Patient Safety Collaboratives.

Launch of Sign Up to Safety campaign

Health and Social Care Act 2008 Health Regulations 2014. Regulation 20 providing for the first time, a statutory duty of candour for health institutions.

NICE publishes first guideline on safe staffing for nursing in adult inpatient wards in acute hospitals.

The Report of the Morecambe Bay Investigation (Kirkup Report).

Publication of the Freedom to Speak Up Review by Robert Francis QC

Public Administration Select Committee report on clinical incidents in the NHS. Recommendation that a new independent patient safety investigation body should be established.

First meeting of Independent Patient Safety Investigation Service (IPSIS) Expert Advisory Group. The IPSIS was later renamed the Healthcare Safety Investigation Branch (HSIB)

Health and Social Care (Safety and Quality) Act

First national safety standards for invasive procedures (NatSSIPs) published by NHS England

Establishment of NHS Improvement, merging functions of Monitor and NHS Trust Development Agency.

Creation of the National Guardian's Office, and Freedom to Speak Up Guardians in NHS.

Establishment of Healthcare Safety Investigation Branch (HSIB).

Publication of National Guidance on Learning frrom Deaths

Report of Gosport Independent Panel into mortality at Gosport War Memorial Hospital. The report showed that concerns had been raised by nurses as early as 1991 about the inappropriate prescription and administration of drugs such as diamorphine, and that the lives of over 450 people had been shortened between 1987 and 2001. However, the scandal only came to public attention following the death of Gladys Richards in 1998, who had been admitted following a hip operation.

CQC Report Opening the Door to Change: NHS safety culture and the need for transformation

Journal Clinical Risk becomes Journal of Patient Safety and Risk Management

Publication of A Just Culture Guide by NHSEI

Report of the Independent Inquiry into the Issues Raised by Paterson

First Do No Harm: The Report of the Independent Medicines and Medical Devices Safety Review (Cumberlege report).

Interim Ockenden report into maternity services at Shrewsbury and Telford Hospital NHS Trust

Publication of introductory version of Patient Safety Incident Response Framework (PSIRF) by NHSEI

Appointment of the first Patient Safety Commissioner, an outcome of the Cumberledge Report (2020). 'The independent commissioner will act as a champion for patients and lead a drive to improve the safety of medicines and medical devices' – Department of Health and Social Care.

Publication of full Ockenden Report into failures in maternity care at Shrewsbury and Telford Hospital NHS Trust

Publication of Kirkup report into failures in maternity and neonatal services in East Kent.

National State of Patient Safety Report 2022, by Institute of Global Health Innovation at Imperial College London, commissioned by the charity Patient Safety Watch. The report draws attention to improvement in various indicators of patient safety at a national level in England, but also ongoing areas of concern, notably around maternity services, staff shortages, access to care, and waiting lists. The report recommends that the breadth of patient safety data needs to increase; that the accuracy of key patient safety measures needs to improve; the need for an urgent workforce plan for the NHS and social care; that Integrated Care Systems should play a central role in monitoring patient safety; and that progress in the safety of maternity services needs to accelerate.