Implementing Patient Safety
Programmes – the story no one ever
wants to tell!
Expert Seminar - Paris
22 – 24 May 2006
Sue Osborn/Susan Williams
Joint Chief Executive
National Patient Safety Agency
“ to improve safety of patients by
promoting a culture of
reporting and learning from
patient safety incidents
affecting patients receiving
National Health Service funded
care”
Purpose of NPSA
Help the NHS to:
• learn from things that go wrong
• develop and implement solutions to problems
• improve patient safety in frontline services
Focus on:
• systems not individuals
• learning not judgement
• fairness not blame
• openness not secrecy
• all care settings not just acute
National Health Service
Northern
Ireland
Wales
Scotland
England
National Health Service
• State funded healthcare system
• 3rd largest employer in the world behind Chinese
Army and Indian Rail Industry
• Biggest organisation in Europe
UK context
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•
•
•
Population 65 million
560 NHS Healthcare Organisations
2 million prescriptions every day
360 million patient contacts over a year
40-50 million clinical decisions per million population per year
Budget £92.6 billion ($170.3 billion)
7% of Gross Domestic Product (US 13.6%)
The National Patient Safety
Agency
• Collect and analyse information on adverse events from local NHS
organisations, NHS staff and patients and carers:
• Assimilate other safety-related information from a variety of existing
reporting systems and other sources in this country and abroad;
• Learn lessons and ensure that they are fed back into practice,
service organisations and delivery;
• Where risks are identified, produce solutions to prevent harm,
specify national goals and establish mechanisms to track progress.
National Reporting & Learning System
•
electronic system to enable NHS organisations,
staff and patients to report patient safety
incidents to a national database
•
links to local risk management systems
Patient safety incident
‘any unintended or
unexpected incident which
could have or did lead to
harm for one or more patient
receiving NHS funded
healthcare’
•
Source: Seven steps to
patient safety: a guide for
NHS Staff (NPSA)
NRLS
Five levels of severity
• No harm
–Those prevented (near miss)
–Those that were not prevented
• Low harm
• Moderate harm
• Severe harm
• Death
NRLS dataset
‘What’, ‘When’, ‘Where’ … and a little ‘How’ & ‘Why’
but NOT Who
notification and basic learning data
hypothesis generating
single high level dataset
specialty extracts
free text to help understanding
data analysis tools
flexibility over time to develop new data fields
stable during national roll out
Overview of analysis of NRLS data
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Routine monitoring reports
Thematic analysis
Ad hoc analysis
Benchmarking information for trusts
Exploratory
– Reviews of selected incidents
– Data mining
• The Patient Safety Observatory: analysis of other data
sources
Patient Safety Observatory
• Building a memory:
Preventing harm,
reducing risks and
improving patient
safety
Number of incidents and reporting trusts
Table of incident reports by care setting
Table of incident reports by degree of harm
Total reported incident types
Who reports:
staff type (where known)
No.
%
Ambulance staff
738
0.58
Dental staff-general and community
135
0.11
Diagnostic and therapeutic staff
5875
4.62
Manager
4629
3.64
Medical staff
9741
7.67
Nurse/midwife/health visitor
87079
68.53
Optician optometrist
12
0.01
Other
12044
9.48
Pharmacy staff
3050
2.4
Support staff (clinical and administration)
3759
2.96
Total
127062
100.00
Reported incident types
•
•
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•
Acute/hospital sector
Ambulance services
Mental health
Learning disabilities
General Practice
Reported incident types in acute/general
hospitals
Reported incident types in ambulance
services
Reported incident types in mental health
services
Reported incident types in learning
disability services
Reported incident types in general
practice
Turning information into learning
Reported incident types in
acute/general hospitals
Acute incidents: medication process
Medication Process
Frequency
%
24791
61.5
Prescribing
6454
16.0
Preparation of medicines
6315
15.7
518
1.3
1778
4.4
269
0.7
Administration/supply
Other
Monitoring
Supply or use over the counter
Description of medication incident
Description
Frequency
%
Wrong/unclear dose or strength
7459
18.5
Omitted medicine
6851
17.0
Wrong drug or medicine
4203
10.4
Wrong frequency
3813
9.5
Wrong quantity
2337
5.8
Wrong/transposed/omitted medicine
label
1661
4.1
Bench marking information: feeding back
to individual organisations
NPSA Activity Analysis
For
Chief Executive,
Foundation Trust
NHS
Feedback to individual
organisations
• Report available to individual organisation via
secure internet site
• Password protected-only NHS organisations can
access
NRLS extranet launch
• New service available to all NHS organisations in England and
Wales from 2 May 2006
• Each NHS organisation has their own individual report providing
a comparison between their data and similar organisations over
a 3 month period
• Similar organisations are “clustered” in line with existing
definitions
• Reports to be made available quarterly
NHS organisation clusters
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Ambulance
Mental Health
Learning Disability
Primary Care Organisations
Large Acute
Medium Acute
Small Acute
Acute Specialist
Acute teaching
Influencing Role
An Example of Influencing Role –
Connecting for Health
• To deliver IT systems which improve clinical safety.
• To provide suppliers with an easy to use and robust
safety management system.
• To provide Trusts with assurance and clear guidance
on the actions they need to take to ensure systems
are deployed in an effective and safe manner.
Requirements
All CfH products and every request to connect with
spine must have:
• End-to-end hazard assessment
• Safety case
• Safety closure report
Must have clinical authority to deploy (issued by
Clinical Safety Officer or Director of Knowledge
Process and Safety) before products can be accepted
into integration testing and deployment
Clinical Safety Organisation
NHS CfH Programme
Board
Risk Reduction Board
Chair: NHS Trust
Clinical Director
NHS CfH Clinical
Risk and Safety Team
Chair: Sir Muir Gray
NHS CfH Clinical
Safety Officer
Maureen Baker
Technical Assurance
Test Manager
Project or Compliance
Safety Officer
Supplier Safety
Officer
Clinical Experts
Clinical Risk Minimisation
Programme of work to that allows identified safety
solutions to be fed into CfH – includes
• Right Patient Right Care
• Safer prescribing
• Safer handover
As problems identified through NPSA’s Patient Safety
Observatory, those with technology solutions can be
fed into CfH through this work programme
Embedding Safety
Educational Module for Junior
Doctors
• Aimed at doctors in second foundation year.
• Module linked to patient safety learning requirements
in AoMRC’s Curriculum for Foundation Years
• Educational material to be available online at
www.saferhealthcare.org
• Material will support clinical tutors in Trusts to deliver
module
Content of educational module
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Principles of human error
Principles of risk assessment
Safer systems
Learning from when things go wrong (including
incident reporting and RCA)
• Being open
• Doctors Net – 39,000 interactions with online
materials on patient safety
Solutions: preventing errors: a hierarchy
Design out the potential for harm
Make incorrect actions correct
Make wrong actions more difficult
Make it easier to discover errors
Preventing errors: a hierarchy
Design out the potential for harm
Preventing Errors: a hierarchy
Before
After
Solutions
information design for patient safety
Good
Good
Bad
Bad
Safe medication practice
• Improving infusion device safety (Safer Practice Notice 02)
• National standards for dispensed medicines
• Oral liquid medicines and feeds (Design)
• Developing a new connector for spinal therapy (Design)
• Guidance on safe medication packaging (Design)
• Reducing patient safety incidents associated with
anticoagulants
• Safer practice with high dose morphine and diamorphine
Solutions / Safer Practices
Forms of NPSA advice
• A patient safety alert requires prompt action to
address high risk safety problems
• A safer practice notice strongly advises
implementing particular recommendations or
solutions
• Patient safety information suggests issues or
effective techniques that healthcare staff might
consider to enhance safety
Learning about falls and use of
bed rails
Acute incidents: patient accidents
Patient Accident Incidents
Frequency
%
128354
91.5
Collision/contact with an object
6098
4.3
Contact with sharps (includes needle
stick)
1519
1.1
Inappropriate patient
handling/positioning
1093
0.8
Exposure to cold/heat (includes fire)
1176
0.8
722
0.5
1355
1.0
6
0
Slips, trips, falls
Exposure to hazardous substance
Other
Not stated
National Reporting & Learning
System: falls
• Analysed random samples of 500 falls in
detail in acute settings
Where do patients fall? (n=500)
fall whilst mobilising
9%
1%
2%
fall from bed
32%
10%
fall circumstances
unclear
fall from chair
fall from toilet or
commode
18%
28%
fall in bathroom or
shower
fall other
Falls from bed (n=140)
3%
7%
fall from bed with
bedrails
36%
54%
fall from bed definitely
without bedrails
fall from bed probably
without bedrails
fall from sitting position
on side of bed
Severity of injury in falls from bed
45
number of incidents
40
35
no harm
30
low
25
moderate
20
severe
15
death
10
5
0
fall from bed
with bedrails
fall from bed
fall from bed
fall from sitting
definitely without probably without position on side
bedrails
bedrails
of bed
100 with/100 without bed rails
site of injuries in fall from bed
number of incidents
25
20
15
no bedrail
10
bedrail
5
0
arm
bottom chest
head leg/hip spine
location of injury
other
Incidents involving bedrails
Incidents directly involving bedrails
no harm
low
moderate
numbers
20
15
10
5
0
caught by
bedrail
struck bedrail
trapped limb
other (bedrail
fell off onto
foot)
Learning about the
misplacement of
nasogastric tubes
Misplacement of NG tubes:
the incident
On Thursday 5th December 2002 an NG tube was inserted to allow
the feeding of an 8 year old girl. The standard tests for placement
were performed and feeding commenced
Unbeknown to all, the tube had been inadvertently inserted through
the trachea and bronchus into the left pleural space
Despite repeated tests the misplacement was not recognised for 24
hours during which time she was fed through the tube
The subsequent chest infection could not be treated adequately and
on 22nd December 2002 the girl died at home
Methods for checking position
•
•
Observation for respiratory distress during insertion
The ‘whoosh’ test
– Insufflation of tube with air whilst auscultating over
epigastrium
•
Testing of NG aspirate for acidity
– Litmus paper
– pH paper
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•
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X-ray
Observing ‘bubbling’ when tube placed under water
Experimental methods
– Use of carbon dioxide detectors
– Enzymatic analysis of NG aspirate
What had gone wrong?
• Understanding gained whilst writing report for Coroner
• Information from:
– Timeline
• Constructed by risk management department
• Based on physiotherapy records
– Statements
– Literature search
– Tests carried out on unit
• Two tests used:
– The ‘whoosh test’
– Testing of aspirate with litmus paper
Coroner’s recommendations
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Alert Trusts about risks associated with litmus paper
‘Whoosh’ test to be withdrawn from use
A review of the next edition of the Marsden Manual
Feed manufacturers to be required to show the pH level of their
food
• Tube manufacturers to include advice on appropriate tests for
placement
• Consideration of a scheme for reporting adverse events and
lessons learnt nationally – National Reporting and Learning
System
NPSA involvement
Coroners recommendations based on one case
• Patient Safety Managers identified 10 more deaths
• Literature review, No test perfect, pH and x-ray most
reliable
• Range of 0.3% - 20% misplacements reported in
literature
• Limited studies in UK, particularly in relation to neonates
• NRLS not in operation at the time
Potential for aggregate Root Cause Analysis
Aggregate RCA
• Powerful method of determining underlying
causes across a number of incidents
• Originally developed in high hazard industries
• Advantage - actions taken to improve care are
based on information from a number of events
and so are more likely to address common
problems.
• Not been done before in UK
Root causes
• Use of unreliable bedside tests
• Limited awareness of risks
• Lack of decision tree
• Lack of competency based training
solution ‘fast tracked’
NG Alert and Carer Briefing
Compliance
• 99% of acute trusts compliant
• 85% of primary care trusts
Learning about MRI scanners
MRI scanners and metal: the risks
• Metal within the body, such as pacemakers, could be
displaced with fatal results.
• Metallic equipment attached to the patient can
malfunction.
• Metal attached to the patient, such as callipers could
result in a dislocation or fracture
• Loose metal objects become projectiles, with
potential for fatal injury if a patient or staff member is
in their pathway.
Starting point
• USA fatalities brought to NPSA attention prior
to NRLS rollout
• Professional bodies ‘guidance is in place in
the UK’
• UK managers state a problem is ‘extremely
rare’
NRLS data
• 526 reports of PSIs in MRI units
• 31 of these reports related to implants
• Five pacemakers, one implantable
defibrillator, one heart valve and three
aneurysm clips went undetected. All of these
are potential fatalities.
NPSA observatory
• NHSLA – pacemaker/MRI fatality
• MHRA – 200 reports related to MRI
• Literature – 14 deaths in other countries
Visits by PSMs
• Small projectiles almost everyday occurrence
• Frontline staff depending on constant vigilance rather
than safer systems
• Significant variations in strength and number of barriers
between units
Proposals
NPSA to work with clinical experts and frontline staff:
• To develop patient centred written and visual
information
• To scope the formation of a comprehensive register
of MRI compatible materials.
• To scope and cost a pilot of additional physical
barriers such as metal detectors.
• To improve staff documentation and procedures (e.g.
referral forms and checklists) to take account of
human factors.
• To support commissioning for patient safety in MRI
Learning for safer
patient
identification
Information from NRLS
• Search on “patient incorrectly identified” =
1506 incidents
Error types
Percent of
total
Error types
Number
a) Mismatches between patients and the
documentation on their samples, records, blood
transfusion samples and products, and
medication.
975
64.7
b) Missing wristbands or wristbands with incorrect
data on them.
236
15.7
c) Mismatches between patients and their medical
records.
155
10.3
d) Failures in the manual checking processes.
140
9.3
1506
100.0
Total
Error type by location in acute/general and mental
health
Location
Ward
Laboratory
Accident and Emergency
Outpatients
Radiology
Operating theatre
General areas
Intensive Care Unit
Day Care Services
Recovery Room
Anaesthetics
Ambulatory Care/
Independent Treatment
Centre
Therapy
Mental Health Unit (ward)
Other
Total
Mismatches
with the
documentation
329
161
121
78
85
48
73
28
10
3
1
Wristband
use
112
4
15
3
14
39
18
14
3
8
Mismatches
with medical
records
46
4
6
41
13
15
17
4
4
Manual
checking
process
53
7
5
19
19
12
4
6
4
1
1
14
952
2
232
1
2
153
2
132
Missing wristbands or wristbands with
incorrect data
Specialty
No wristband in place
Incorrect data on the wristband
Totals
Surgical Specialties
29
37
66
Medical specialties
28
22
50
Diagnostic services
25
10
35
Obstetrics and Gynaecology
25
9
34
Accident and Emergency
5
7
12
Dentistry-General and Community
1
Anaesthetics
1
1
1
Other
13
24
37
Total
126
110
236
NPSA patient ID programme
Wristband Safer Practice Notice Nov
2005
Identified 236 reports to NPSA of errors
concerned with missing or incorrect
wristbands
Action for NHS:
•Ensure acute hospital inpatients wear
wristbands that accurately identify them
•Make effective arrangements for
implementing and monitoring this action
Solutions work programme:
• Right Patient, Right Care
• Correct site surgery (Patient Safety Alert 06)
• Wrist band compliance (Safer Practice Notice 11)
• Standardisation of wrist bands
• Exploration of bedside checking
• Programme of work to reduce the risk of patients
receiving the wrong blood during transfusions
Learning from deaths
Crash call trolley incidents –
Jan – Feb 2005
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•
•
•
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•
Delay in response to crash call.
No support given by ward staff to patient who had arrested until arrival of crash call doctor.
Door locked/no equipment/ no resuscitation attempted despite no knowledge of patient
status re resus.
Attempt to call crash team to collapsed patient. Subsequently found that crash call phone
in switchboard accidentally left off the hook.
Patient coughing up some bright red blood following radiotherapy. Crash Team call.
Apparatus missing from crash trolley/emergency lights not working/insufficient staff to
cope with the situation.
Patient suffered cardiac arrest. Crash trolley found not to have been replenished with
essential drugs following previous use.
Equipment on crash trolley was incomplete rendering it unusable and delaying the ability
to remove vomit of patient to obtain a clear airway.
Cardiac arrest call. Incomplete equipment on crash trolley meant unable to provide
appropriate care.
Patient collapsed whilst on commode in community. Dr called and declared patient dead.
After doctor left patient found to be alive. Crash team called.
2 PSIs for same incident. Patient’s condition declined to cardiac arrest without appropriate
monitoring or outreach team being called.
Example of NRLS/PSO -tracheostomy
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Clinical concern re transfer from ICU to general wards
NRLS: 36 incidents, one death
NHSLA: 45 litigation claims Feb 96 to April 05, of which 13
related to the management of tracheostomy tubes,
including 7 deaths
MHRA: 10 similar incidents since 1998
HES: increase in tracheostomies being performed in the
last 5 years, and a higher proportion of patients who have
had a tracheostomy being cared for outside of surgical
and anaesthetic specialties
NPSA Bulletin
Scoping work with other organisations
NRLS: other examples of analysis and
issues identified
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•
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patient ID problems in lab tests – lab results or samples being mis-identified
non-medical devices/IT equipment – errors or failure of computing and other
non-medical equipment leading to incidents
missed/delayed diagnosis – incidents relating to this, particular in
emergency care
infusion pumps – inappropriately attaching an infusion pump line to an
intravenous line
pre-filled syringes – supply problems of emergency pre-filled syringes
oxygen cylinders – people smoking near use of oxygen, cylinders falling on
people
bleeps not working, leading to failure to respond to urgent calls
Fire and burn risk from skin preparations and diathermy
Swabs missing from surgery
Summary of ambulance NRLS data
1/4/05 – 30/06/05
• Patient accident (33%)
– Injury from vehicle steps
– Instability of trolleys and chairs
– Patient falling
• Access/admission/transfer/discharge (29%)
- OOH care
- Transfer of Care
• Consent/communication/confidentiality (11%)
- Prioritisation of calls
• Medical device/equipment (11%)
– Defibrillator failure
• Treatment procedure (5%)
• Consent, communication, confidentiality (3%)
Are we learning from these
tragedies?
Evaluation and Impact
Patient Safety Alert
Impact
Potassium Chloride
Patient Safety Alert 01(2002)
• 100% reduction in deaths since 2002
• 97% uptake of actions
Crash call
Patient Safety Alert 02 (2004)
• Survey in 2002 indicated 27 different numbers being
used for crash calls across 173 trust
• 100% compliance. All trusts using 2222
Methotrexate
Patient Safety Alert 03 (2004)
• 87% of GP practices have implemented safety alert
Cleanyourhands
Patient Safety Alert 04 (2004)
• 99% of trusts in England and 100% of hospitals in
Wales implementing cleanyourhands campaign
Nasogastric Feeding Tubes
Patient Safety Alert 06 (2005)
• 99% of acute trusts in England have implemented this
notice.
Correct Site Surgery
Patient Safety Alert 06
• 70% of acute trusts in England have completed the
actions and 38% of acute trusts in Wales
NHS Health Organisations - The Road to Resilience
8,000 NHS staff
trained in Root
Cause Analysis
7 Steps to
Patient Safety
General and
Primary Care
National
Reporting and
Learning
System
Cultural Tools
Being Open
MaPSaF
Scenario
Based
Decision
Making
Foresight
Training
Chief Exec
Checklist and
Board
Training
Incident
Decision
Tree
Feedback
PSO Bulletin
Extranet
Patient &
Public
Reporting
Vulnerable – High Reliability - Resilience
Proactive
Risk
Assessment
Toolkits
The Challenges Faced
The Future
NHS Health Organisations - The Road to Resilience
8,000 NHS staff
trained in Root
Cause Analysis
7 Steps to
Patient Safety
General and
Primary Care
National
Reporting and
Learning
System
Cultural Tools
Being Open
MaPSaF
Scenario
Based
Decision
Making
Foresight
Training
Chief Exec
Checklist and
Board
Training
Incident
Decision
Tree
Feedback
PSO Bulletin
Extranet
Patient &
Public
Reporting
Vulnerable – High Reliability - Resilience
Proactive
Risk
Assessment
Toolkits
“A structured systematic means for ensuring
that both general and particular aspects of
what the organisation does are effectively
managed to meet the high standards of
safety.”
Reference: Waring A (1996) Safety
Management Systems. London: Chapman
and Hall
Senior Management Commitment
• Safety is a primary goal of the organisation.
• Senior management has the ability to drive safety
systems.
• Identified person(s) to take responsibility.
• Open communication about safety issues.
• Appropriate resource allocation to address concerns.
• Integration of safety with other management
systems.
A Proactive approach to Risk
• Formal and informal meetings about safety.
• Risk assessments considered a part of every day working
practices.
• Integration of known risks and potential risks incorporated into a
register for all risks (a risk register).
• Links between the risk assessment process and business
performance.
• A clear understand of how those risks can be managed through
defences and controls.
• Solutions to minimise risk.
• Changes to procedures to work around the risk.
• Communication about risks to staff and public alike.
Reactive Processes
•
•
•
•
Open and fair culture.
Confidential reporting systems.
Feedback on information and action taken.
Incident analysis used to identify conditions which
need correction – informing risk assessment
processes (moving from reactive to proactive
approach).
Accountability and Follow Up
• Risk registers translated into action plans.
• Action plans describe specified accountability.
• Risk register and action plans (and risks themselves)
are monitored and reviewed through audit processes.
• Formal assurance processes to show that reporting
goals have been achieved.
• Feedback.
NPSA Guidance
Safety Check List
Senior Management
Commitment
Proactive
Approach to Risk
Reactive
Processes
Safety Management System
Accountability
and Follow up
Delivering safer healthcare –
A leadership checklist for NHS Chief
Executives
“…The ability of a system or organisation to
react to and recover from disturbances at
an early stage, with minimal effect on the
dynamic stability.”
Reference : Hollnagel E, Woods D and Leveson, N (Eds).
Resilience Engineering. Ashgate Publishing, in press, due
for publication January, 2006.
How do Staff
•
•
•
Prevent something bad from happening?
Prevent something bad from becoming worse?
Recover from something bad once it has happened
to minimise harm?
Reference: Westrum R. Being resilient. In: Hollnagel E, Woods D and
Leveson, N (Eds). Resilience Engineering. Ashgate Publishing, in press,
due for publication January, 2006.
Reference: Reason, 2005
Features of Local Safety Units
It is proposed that each unit:
• is integrated into the Chief Executives network in the Health Authority;
• works closely with the Strategic Health Authority to ensure patient safety is
core to the targets for Trusts and the performance management and
improvement work;
• is aligned with a University Department(s) conducting research into safety;
• has expertise in human factors and design;
• has resources to provide training in the fundamentals of patient safety;
• delivers the ‘Patients for Patient Safety’ initiative locally;
• takes the lead nationally for a particular area such as mental health,
vascular surgery or general practice (as has been the model with Public
Health Observatories);
• develops solutions to local safety problems and disseminates these across
all Units;
• engages experts from safety conscious industries in the area to transfer
expertise from these industries into healthcare;
The following diagram sets out the different
elements of a programme for a health community:
Strategic Health Authority: agreement of role and remit, including how support
can be accessed across an area (eg: local safety units)
Work with the providers of under and
post-graduate education and the KSF*
Patient and public involvement
Programmes that address issues across
all levels within organisations
Board and senior manager programmes – some
specific to the organisation, some generic across
organisations
Organisational programmes – some specific to the
organisation, some generic across organisations
 Clinical safety programmes designed to address
specific safety issues in each organisation (eg:
eliminating central line infections or preventing
patient suicides)
 Clinical safety programmes designed to address
issues across and between organisations (eg:
discharge summaries or medicines reconciliation)
Support from safety experts in other local industries
*KSF – Knowledge and Skills Framework
Patient Safety at National Level
– Functions at a National Level
•
•
•
•
•
•
Bearing in mind the criteria above, we believe that there are a number of
functions that should continue to be discharged at a national level, at least in
the medium term.
managing the national reporting and learning system. The WHO guidelines
for adverse event reporting and learning systems state that the system must
be confidential and safe for the individuals who report and reporting must
lead to a constructive response. It is important that these principles continue
to be reinforced;
developing robust mechanisms to provide regular reports back to both
organisations and the public about the information collected, demonstrating
learning from reports and facilitating the spread of knowledge and solutions
developed at a local level;
drawing together information on risks in the health care system to inform
future direction, priorities and action through the Patient Safety Observatory;
influencing health service policies at a national level to enable safety to be
embedded across all policy areas for example CfH, HR, finance, regulation,
development of educational curricula and performance management;
coordinating work across a range of national organisations with key roles in
safety – e.g. Royal Colleges, other ALBs.
Patient Safety at National Level
– Functions at a National Level – cont’d
•
•
•
•
•
•
•
influencing national initiatives such as purchasing and information
technology;
influencing at the EU level in areas such as the free movement of
professionals, the regulation of drugs and healthcare devices;
providing expert advice distilled from a wide range of safety conscious
industries and university departments and translating this into the
healthcare setting;
influencing healthcare industries to improve safety including drugs and
medical devices;
developing tools and techniques to support staff across the NHS in
delivering the fundamentals of patient safety, such as the ‘Seven Steps to
Patient Safety’, the RCA toolkit and prospective risk assessment methods;
developing methodologies for involving and engaging with patients and
the public on patient safety;
developing national solutions, for example the Potassium Chloride Alert,
which required work at a national level with the pharmaceutical industry to
ensure that diluted product was available across the NHS;
Features of a National Function
• organisational values aligned with the ‘open and fair’
culture associated with successful safety systems;
• trusted that reports will be used for learning rather
than for punitive purposes;
• sufficient authority and independence to publish data
and learning in a timely and regular fashion;
• credibility with patients and the public;
• linked with local safety units, with mechanisms for
them to be formally represented within the national
function;
• governance arrangements that facilitate stronger ties
with and buy-in from national and local stakeholders.
Summary
Now that the NRLS is in place and many of the building
blocks of a safety system have been developed, if not
yet fully embedded, we believe that we have a reached
a point where it is appropriate to enhance the skills and
resources for patient safety at an intermediate and local
level. Alongside this there remain major national roles to
both support and encourage local delivery and to provide
national leadership and action where there is clear benefit in
national delivery, policy and influence but……..
Implementing Patient Safety
Programmes – the story no one ever
wants to tell!
Expert Seminar - Paris
22 – 24 May 2006
www.npsa.nhs.uk