The Work of the National Patient
Safety Agency
Joan Russell
Safer Practice Lead-Emergency Care
Overview
• Patient safety – what, why and how big is the
problem?
• Seven steps to patient safety and the tools to
make a difference
• Ambulance Service Risk Assessment
Patient Safety – A global issue
18
16
14
USA 3.7%
Australia 16.6%
England 10.8%
Denmark 9%
New Zealand 12.9%
Canada 7.5%
Japan 11%
12
10
8
6
4
2
0
% of acute admissions
Cost of unsafe care each year in the UK…
• 10% of admissions = 900,000 patients affected
• around £1 billion/year in extra hospital stay costs
• average 8.5 extra bed days
• 400 people die or are seriously injured in incidents
involving medical devices
• >£450 million clinical negligence settlements
• over £1 billion spent on hospital associated infections
• £29 million direct costs related to staff suspension
Background
• An organisation with a
memory
• Building a safer NHS for
patients
Seven Steps
1.
2.
3.
4.
5.
6.
7.
Build a safety culture that is open and fair
Lead and support your staff in patient safety
Integrate your risk management activity
Promote reporting
Involve patients and the public
Learn and share safety lessons
Implement solutions to prevent harm
Step 1 - Build a safety culture that is open
and fair
• Safety is considered in everything you do
• There is a balanced approach when things go
wrong - you ask why and not who
• Constant vigilance
NPSA Definitions
NO HARM
PATIENT SAFETY
INCIDENT
Any unintended or
unexpected incident(s)
which could have or
did lead to harm for
one or more persons
receiving NHS
funded care
LOW
MODERATE
SEVERE
DEATH
Prevented, i.e.
not impacted on
patient (previous
near miss)
Not prevented,
but resulted in
no harm
Patient safety e-learning programmes
• the perfection myth
– if we try hard
enough we will
not make any
errors
• the punishment myth
– if we punish
people when they
make errors they
will make fewer of
them
Incident Decision Tree
Step 2
Leadership and support
Leadership advised to:
• Undertake executive walkabouts
• Develop team safety briefing and debriefing
• Appoint patient safety clinical champions
• Undertake safety culture and team culture
assessments
Step 3 - Integrated risk management
•
•
•
all risk management functions and information:
–patient safety,
–health and safety,
–complaints,
–clinical litigation,
–employment litigation,
–financial and environmental risk
training, management, analysis, assessment and
investigations
processes and decisions about risks into business and
strategic plans
Step 4
Promote reporting
• National reporting and learning system (NRLS)
• Reporting via:
– local risk management systems
– E-form on NHS net
– E-form on www
• Anonymous (names of patients and staff)
• Confidential (names of organisations)
National reporting and learning system
NHS
reports
NRLS
monitor
impact
test &
implement
solution
Improved
patient
safety
design
solution
identification of issues
prioritisation of solution work
Step 5
Involve and communicate with patients
and the public
Being Open
Ask about medicines leaflets
SPEAK UP
Involve in investigation
Step 6 Learn and share safety lessons
• NPSA Root
Cause Analysis
Programme
• Over 5000 NHS staff trained
in RCA methodology
• E-learning toolkit
• Guidance
• Aggregated themed RCA
• RCA data capture
• Training for independent
investigations
Step 7
Solutions to Prevent Harm
• Address root causes
• Make designs of equipment, systems, processes,
more intuitive
• Make wrong actions more difficult
• Make incorrect actions correct
• Make it easier to discover error
“Telling people to be more careful doesn’t work”
Ambulance Service Risk Assessment
• To identify existing risks at each stage of the
emergency response process
• To identify possible risk solutions for high risk issues
• Develop a solutions programme of work
Process
•
•
•
•
•
•
Identification of risks
Identification of causes, consequences and controls
Prioritisation of risks
Identification of solutions
Re-evaluation of risk
Cost/time effectiveness
Key Themes
•
•
•
•
•
Prioritisation/triage
Health Care Associated Infection
Managing Demand
Transfer of Care
Equipment Design
Patient
Safety
Info
Patient safety observatory and
prioritisation process
submissions
PSO
NRLS
and
other
data
sources
NPSA work
programme
NPSA
Board
Expert
Advisory
Panel
Filtering of submissions
Affordances
How would you operate these doors?
Push or pull? left side or right? How did you know?
A
B
John R. Grout
C
Which dial turns on the burner?
Natural Mappings
Stove A
Stove B
What Can Be Done
to Remove Problems ?
•
•
•
•
•
Design out the problem
Change the system
Change practice
Train the staff
Involve patients
• Design out the
problem
(design solution)
Clear design
Case Examples
Cleanyourhands campaign
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
1st team of engineers…
Task-‘replace centre console light panel around the throttle
quadrant’
• Throttle levers in full power position
• Take-off warning horn silenced
• Circuit breaker pulled
Next engineer…
Task-‘trouble shoot a reported engine oil quantity discrepancy’
Requirement of task-undertake an engine run
Guidance-’Pre Power On’ Taxi/Towing Checklist
• Check circuit breakers
• Throttle levers to idle
• Parking break set
To err is human
To cover up is unforgivable
To fail to learn is inexcusable
Sir Liam Donaldson
Chief Medical Officer
England
Thank you for listening
Any questions?
Need help contact;
www.npsa.nhs.uk