An Introduction to the Patient Safety First Campaign for England

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An Introduction to the Patient Safety First
Campaign for England

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Where are we nationally?

• There were around 12 million admissions to NHS
  Acute Trusts in 2006/07.
• Estimates suggest that one in ten patients in
  hospital experience an incident which puts their
  safety at risk, and that about half of these are
  preventable.

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What these figures might mean to you locally

• Potentially an average of 7,300 patients per year
  per hospital suffer an adverse event.
• A double decker bus seats 73 people.
• 100 bus loads of patients per year per hospital.
• Nearly 2 bus loads per week per hospital.

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REGULATED
HAZARDOUS
ULTRA-SAFE
(gt1/1000)
(lt1/100K)
100,000
Health Care
Driving
10,000
1,000
Scheduled
Airlines
Total lives lost per year
100
Chemical
European
Mountain
Manufacturing
Railroads
Climbing
10
Bungee
Chartered
Nuclear
Jumping
Power
Flights
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1
10
100
1,000
10,000
100,000
1million
10million
Number of encounters for each fatality
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A Recent UK Retrospective Case Note Study

• 8.7 of admissions had at least one adverse event
• of which 31 were judged preventable.
• 15 of adverse events led to an impairment or
  disability that lasted gt than 6 months.
• 10 contributed to patient death.
• Increased mean length of stay 8 days.
• Sari AB-A, Sheldon TA, Cracknell A. (2007)
  Extent, nature and consequences of adverse
  events results of a retrospective casenote
  review in a large NHS hospital. Qual Saf Health
  Care 16434-9

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The Campaign cause and aim

• The cause
• To make the safety of patients everyones highest
  priority.
• The aim
• No avoidable death no avoidable harm.

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What makes this Campaign different?

• Seeks to build the will and help with the
  execution.
• Seeks to create a movement.
• Voluntary sign-up.
• Cause and aim applicable across whole NHS.
• Is not Government-led.
• For the service by the service for patients.
• Is led by a team of clinicians and managers from
  across England.

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Campaign Team
Carole Smee, Royal Liverpool Hospital
Ann Keogh, Heart of England NHS Foundation Trust
Martin Bromiley
Steve Brown, United Bristol Hospital NHS Trust
Mike Williams, NHS Research Fellow, Exeter
University
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Who is signed up to the Campaign?

• 252 Trusts have signed up to the Campaign.
• Including Acute, Primary Care, Mental Health and
  Ambulance Trusts.
• 83 per cent of all Acute Trusts have signed up.
• 13 key organisations are signed up.
• Including Royal Colleges.

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How will we make patient safety everyones
highest priority?

• Asking local leaders to give a public statement
  to their staff.
• Promoting the use of a number of evidence based
  interventions.
• Providing initial resources for individuals and
  teams to begin implementation.
• Influencing other key organisations to engage
  with the Campaign cause.

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The interventions

• Leadership for Safety.
• Reducing harm from deterioration.
• Reducing harm in critical care.
• Central line and ventilator care bundles.
• Reducing harm in perioperative care.
• The surgical site infection bundle and WHO
  Surgical Safety Checklist.
• Reducing harm from high-risk medicines.
• Includes anticoagulants, narcotics, insulin,
  sedatives.

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Development areas

• Interventions currently being developed include
  reducing harm from
• Venous Thrombo-Embolism
• Peripheral Lines
• Falls
• Surviving Sepsis.
• Human Factors guide.
• These will be rolled out over the coming months.

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Supporting resources Campaign website

• Register at www.patientsafetyfirst.nhs.uk
• Provides a wealth of resources to support your
  organisation in its implementation including
• Up-to-date campaign news.
• Intervention How-to Guides.
• Marketing materials.
• Upcoming events.
• Plus access to
• Community forums to discuss issues.
• Contact database to aid networking.

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Questions, comments?

• If your query has not been answered in this
  session please contact the Campaign office who
  will be able to provide further assistance.
• Email info_at_patientsafetyfirst.nhs.uk
• Telephone [phone]

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Supporting resources - Events

• Global Trigger Tool training commenced in Oct
  08.
• WebEx series interactive web-based seminars to
  assist implementation were run in Sep 08 with
  further sessions planned for the New Year.
• Regional cluster meetings commenced in Nov 08
  which bring together Trusts to support safety
  improvement work.
• Open Days commenced in Dec 08. They provide
  practical insights into implementation.

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Further information

• Email and telephone support is available from the
  Campaign office.
• Email info_at_patientsafetyfirst.nhs.uk
• Telephone [phone].

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Responding to deteriorating patients.

Documentation Issues. From October 2003 Nursing
Observations lacking Medical Action.   Hypotension
.e.g. lt 100/60 for gt20 observations   Hypothermia.
e.g. 32.4C after daily drops of 1C.   Inadequate
Input/Output Chart notification. e.g. 0.4L/day
input for 2/52.   Several gaps of two or more
days without any medical notes written.
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Responding to deteriorating patients.

ADEs Adverse Drug Events 11/15   i.e. IVI
prescription. Inadequate, excessive or
wrong. e.g. Dextrose saline 3L/24hrs till
hyponatraemic.   Warfarin interaction with
antibiotics. e.g. INRs gt10 after metronidazole or
cotrimoxazole addition to level
INR.   Beta-blockade withdrawal problems. e.g.
dysrhythmias present later.   Hospital Acquired
Infection. MRSA or C.Difficile. et.al. in
alcoholics with CVPs.   NSAIDs on bowel and
kidney. Poor Thromboprophylaxis
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Responding to deteriorating patients.

2/52 in February 2008.
4/52 in April 2008.
Patient Safety Transformation Team
investigates. Use of the Global Trigger Tool.
(Improvement methodology)
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Responding to deteriorating patients. Learning
from our Failures.

37F. Diabetic, LRTI. Double Red O/A.
9hrs. RR44, HR133, sats89. Antibiotics not
given. ?HONK distraction.
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Responding to deteriorating patients. Learning
from our Failures.

92M. CVA. Hypothermia, rhabdomyolysis. Trop
0.265, C.diff. Anti-hypertensives stopped.
Inadequate observation frequency.
Early process failures.
84M. 2/7. COPD. Frequent Re-admissions 4/12. EWS
red RR. Slow antibiotic. E. coli blood culture
Slow treatment
81F. LRTI. 10hrs. 39.8C, HR130. No IVI or
Antibiotics. ?PE ! Wrong diagnosis
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Responding to deteriorating patients. Learning
from our Failures.

Later failures.
58M. Post hemicolectomy. 47/7. Medical
nursing notes absent. HR176, Beta-block stop.
No escalation to doctors.
72F. Gallstone pancreatitis. 4/7. ERPC no notes.
EWS response then 2hrly obs only. HDU/ITU plan.
Post procedure death
63M. Alcoholic. 6/7. ATSP goes to HO only. No
700 call. Failure to escalate OGD worsens.
Post-procedure death HAS delays. Process failure
88F. Mugged at home.14/7. Psychiatric referral.
No admission proforma. DME/surgical/ENT
hand-offs. Process failure. CXR air under
diaphragm. PACS down. LRTI. Technical
failure Diet concern in cachectic 41kg 1.67m.
Referral failure Desire to die. No DNR. Slow 2222
call. End of life failure.
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Responding to deteriorating patients. Learning
from our Failures.

21F Pregnant 20/52. 15/7. Hyperemesis. Found dead
in bed. TB test delay. Abdominal Miliary TB
. Too many handovers/ward moves.
86M. NOF.op. 8/7. Sudden death. PM. Missed
diagnosis. Strangulated hernia, intestinal
obstruction, aspirated vomit.
Late deaths.
41M. Alcoholic Liver Failure. MCV 148. Hb 5.5.
HDU/ITU 2/7. Staph pneumonia. Blood cultures on
every alcoholic?
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Responding to deteriorating patients. Designing
to do differently.

The average was at 6/week.
Outreach and EWS has made the difference.
How do we move below an average of 3/week?
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Red Flags

• Young
• Alcohol
• Drugs
• Psychiatric History

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Responding to deteriorating patients. Designing
to do things differently.

Post-2222 briefing. Post-take ward round.
Doctors Nurses inform Consultant of 2222.
End of life decision failures? Failure to
increase frequency of observations? Failure to
escalate? SBAR use and value? Outreach ITU
support? Adverse Drug Events? Post-procedure
death ?
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Questions, comments?