The National Patient Safety Agency

Of the top 20 risk factors which account for nearly three quarters of all deaths annually, adverse in-hospital healthcare events come eleventh. This is above air pollution, alcohol, drugs, violence, and road traffic accidents, and approaching one third of the deaths due to tobacco. The NPSA was established to be the driving force to improve patient safety. The NRLS is the most ambitious national confidential reporting system in the world. This will inform future research and the development of systems solutions rather than a knee-jerk reaction of individual blame. An important lesson from other industries is that an open and fair culture where safety problems are acknowledged is more important than attributing blame or issuing punishments and sanctions. The NHS spends millions annually on litigation and yet few of these cases lead to national changes in practice. The NPSA aims to change that.