National Patient Safety Agency Clive Tomsett Assistant Director of Safety Solutions

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National Patient Safety AgencyClive
TomsettAssistant Director of Safety Solutions
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The scale of the problem

• 10.8 of patients experienced an adverse event
• Retrospective review of 1,014 records
• Half of these events were preventable
• A third of adverse events led to moderate, or
  greater disability, or death

1Adverse events in British hospitals
preliminary retrospective record review, Vincent
et al BMA 2001322 517-9
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The estimated scale of the problem acute sector

• 900,000 patient safety incidents per year across
  the NHS
• 3,000 patient safety incidents per hospital
• More than 1,000 of these will have moderate to
  severe consequences
• 27,000 extra bed days
• Average cost, per hospital, of 7.4 million

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Patient safety myths

• The perfection myth
• If people try hard enough, they will not make a
  mistake
• The punishment myth
• If we punish people when they make mistakes, they
  will make fewer of them
• Remedial and disciplinary action will lead to
  improvement by channelling or increasing
  motivation

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Systems approach the how, not the who
We must stop blaming people and start looking at
our systems. We must look at how we do things
that cause errors and keep us from discovering
them..before they cause further
injury Lucian Leape Error in
Medicine JAMA 1994 272 1851-1857
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Incident Decision Tree
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Root Cause Analysis
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About us (i)

• We
• were established July 2001
• are a Special Health Authority
• have been created to coordinate efforts to
  identify and learn from patient safety incidents.

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About us (ii)

• Our objectives are to
• 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 organisation and deliver
• where risks are identified, produce solutions to
  prevent harm, specify national goals and
  establish mechanisms to track progress.

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About us (iii)

• Not a regulatory body
• Not performance management
• No disciplinary powers
• Share information
• Issue alerts/advice on good practice

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Background (i)

• Created following the publication of
• An organisation with a memory, which looked at
  learning from adverse incidents in the NHS
• and
• Building A Safer NHS for Patients, which set out
  the governments plans to address AOWAMs
  recommendations.

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The guide (ii)

• Step 1 Build a safety culture
• Step 2 Lead and support your staff
• Step 3 Integrate your risk management activity
• Step 4 Promote reporting
• Step 5 Involve and communicate with patients and
  the public
• Step 6 Learn and share safety lessons
• Step 7 Implement solutions to prevent harm

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Patient Safety Managers (i)

• 31 patient safety managers (PSMs), one for each
  Strategic Health Authority in England and NHS
  Region in Wales
• Building frontline will, skill and capacity for
  patient safety improvements
• Marrying a large national initiative with local
  realities - no one size fits all

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National Reporting and Learning System (ii)

• Purpose of data collection is learning - to
  analyse data to identify patterns, trends and
  risks to patient safety, provide feedback
• Extensive work on dataset, two pilot stages in 39
  NHS Trusts (MH, PCT, acute, ambulance) and with
  vendors of LRMS
• Extensive work with vendors on LRMS integration

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National Reporting and Learning System (iii)

• Identify and record three types of incident
  those that have happened, those that have been
  prevented, and those that might happen
• Store anonymised information which will be
  analysed to discover patterns and underlying
  contributory factors
• Will be able to identify originating NHS
  organisation and exploring methods for providing
  feedback in the future

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Safety Solutions

• Overview
• Alerts
• Wrong Site Surgery
• Team Self Review

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Solution development What would you do?
JFK International terminal mens restrooms
a) hire an attendant to monitor and reprimand
less hygienic users
b) periodically plot spillage area on an X-bar
chart, look for special causes

• c) double the size of the fixtures

Source Wall Street Journal, used by John Grout,
NPSA Seminar, 17 January 2003
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Solution development

• d) etch the image of a fly on the porcelain

Source Wall Street Journal as used by John
Grout, NPSA Seminar 17 January 2003
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Safety Solutions (i)

• We have a wide range of patient safety solutions
  development projects underway
• Once fully developed and tested, practical
  solutions will be shared with the service for
  implementation locally
• We will also issue alerts with advice where we
  identify serious patient safety issues

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Safety Solutions (ii)
Example of an NPSA Patient Safety Alert
Preventing Accidental Overdose with Intravenous
Potassium
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Perceptions of Wrong

• Public confidences of wrong failures can be
  devastating for all involved, (professional,
  organisational and personal reputations)
• Systems failure / communication breakdowns

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Wrong Site Surgery covers not only surgery
performed at the wrong anatomical site (incorrect
finger on the correct hand), but also

• Wrong patient
• Wrong side (left / right)
• Wrong level (spine)
• Wrong operation (glaucoma instead of cataract)
• Wrong implant/prostheses (hip or eye)
• Wrong orientation of implant (lens implant for
  correct patient, site side but implant
  inverted)

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To Mark or Not To MarkThat Is The Question

• or X ?
• Both or one side ?
• Wrong side marked ?
• Other Marks ?

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Team Self Review (TSR)

• NPSA work with Royal Cornwall Hospitals NHS Trust
  (wider collaborative with NCGST / Aston)
• Briefing debriefing of theatre teams
• Human Factor CRM transfer to theatres
• Provides a framework for the team to discuss
  teamwork performance through 15 health
  dimensions
• Enables the team to identify, implement and
  monitor behavioral changes to enhance performance
• Process has produced tools (TSR guide and cards)

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Theatre Team De-briefing

• Team Health Model
• 5 key areas of team health each comprising 3
  health dimensions

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Theatre Team De-briefing
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TSR Issues Raised (21 23 reviews)