Patient Safety in Anatomic Pathology
Moderator: Peter Furness
Section 5 -
United Kingdom Patient Safety Initiatives
Peter Furness, BM BCh, PhD, FRCPath
Leicester General Hospital
Department of Pathology
Leicester , UK
The presence in the UK of the National Health Service, which delivers medical services free at the
point of delivery to the entire population, has created a unique platform for the implementation of
international developments in patient safety. To achieve this, the National Patient Safety Agency (NPSA)
was established in July 2001 with the stated aim of co-ordinating efforts to identify and learn from
patient safety incidents.  Its intention was to make the National Health Service "an organisation with a memory".
However, it has become clear that having a memory is not sufficient; to be effective, such an
organisation also needs a sensory system, a data processing system and a motor system which is capable of
The main sensory system of the National Patient Safety Agency is the "National Reporting and Learning
 This aims to channel irreversibly anonymised information about every patient safety
incident throughout the NHS into the NPSA's database. Every hospital (and, increasingly, every primary
care provider) is expected to have a risk management database into which reports of patient safety
incidents are fed. After some technical teething problems, virtually all NHS hospitals and a growing
number of primary care organisations have connections established so that anonymised data from these
local risk management systems are fed into the national database.
The result is data collection on patient safety incidents on an internationally unprecedented scale.
There are, of course, other routes for data input. The NPSA has developed an on-line system for
direct reporting of incidents, available to members of the public and to staff who, for whatever reason,
are reluctant to report potentially embarrassing information through their local hospital management
system.  Information also comes from letters, telephone calls, literature searches and so on, but in
volume these are dwarfed by the data input to the NRLS.
The huge volume of data has caused serious processing problems, for which a variety of strategies have
Within pathology, it rapidly became obvious that relevant patient safety incidents were coded as "a
pathology incident" relatively rarely. The majority related to incidents involving specimens on the
wards or reports after they have left pathology, and were therefore coded under the relevant clinical
discipline or hospital location. Other strategies were therefore needed to extract from the mass of data
those incidents relevant to pathology.
We cannot assume that information entering the NRLS is complete or unbiased. However, with that
caveat, by far the commonest type of patient safety incident reported is in the pre-analytical phase.
Errors in specimen identification, delays in transport and specimens disappearing before they arrived at
the laboratory are numerically far more significant than incidents occurring within the laboratory.
The second commonest problem is post-analytical errors; reports going missing, not being read or acted
upon, or misunderstandings in the verbal communication of urgent results.
Incidents occurring entirely within the laboratory tend to excite much more concern from pathologists,
perhaps as there is a greater sense of personal responsibility. But in relation to overall patient
safety it would appear that pathologists should be reaching beyond the laboratory and taking more
interest in problems at their interface with other healthcare staff.
Processing NRLS data has so far proved extremely laborious. Sophisticated language analysis software
has been purchased, but has proved to be of little value within pathology. Incidents can be stratified
according to the reports stated impact on the patient, but there are serious problems in the quality of
coding by those reporting the incidents, and it is of course possible for a "near miss" with no patient
impact to have profound implications for improving healthcare.
The National Patient Safety Agency has developed several "motor" functions to try to achieve
improvements. The most visible is the intermittent production of patient safety alerts and notices,
disseminated throughout the National Health Service, but these can only impact on selected, specific
problems.  NPSA projects are developed though a formal prioritisation process, with much of the input
to that process now coming from the NRLS. For example, one current initiative is targeting improvements
in patient identification, a topic of clear relevance to pathology's problems. 
Considerable effort has been put into changing the culture of the health service. A variety of
publications and electronic tools have been produced to persuade staff to avoid the futile attribution of
blame where adverse consequences were genuinely unintended,  and to concentrate on learning from safety
incidents. Training in root cause analysis has been provided to staff in all NHS hospitals, and packages
are available on the NPSA website. 
But there remains a problem in relation to disseminating information about small, everyday
improvements in safe practice which are relevant to only a small number of healthcare practitioners.
This is commonly the case in pathology, where national patient safety alerts addressed to the entire
health service workforce would be excessive. As a partial solution to this the National Patient Safety
Agency has established an internet-based mailing list for the discussion of patient safety issues, which
is open to any relevant healthcare staff.  This has provided interesting discussions of
pathology-specific patient safety topics, often prompted by data from the NRLS. Its use however, is
sporadic. More work needs to be done in developing mechanisms to extract and disseminate lessons from
the NPSA's data collection systems.
- The National Patient Safety Agency homepage. http://www.npsa.nhs.uk/
- NPSA incident reporting – the NRLS. http://www.npsa.nhs.uk/health/reporting
- NPSA online incident reporting – the 'eform'. http://www.npsa.nhs.uk/health/reporting/reportanincident
- NPSA Alerts and Advice. http://www.npsa.nhs.uk/health/alerts
- NPSA initiative on patient identification. http://www.npsa.nhs.uk/site/media/documents/1440_Safer_Patient_Identification_SPN.pdf
- NPSA Incident Decision Tree. http://www.npsa.nhs.uk/health/resources/incident_decision_tree
- NPSA Root Cause Analysis training. http://www.npsa.nhs.uk/health/resources/root_cause_analysis
- 'Safer Pathology'; an NPSA internet mailing list. http://www.npsa.nhs.uk/health/resources/elists