Building a safer NHS the role

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Building a safer NHS the role work of the
National Patient Safety Agency
Dr Sally Adams Head of Incident Investigation
Risk
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Overview

• Setting the scene
• Overview of NPSA
• Seven Steps to Patient Safety

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Complexity

• NHS is the worlds third largest employer
• Size, diversity and geography difficulties for
  shared learning

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Culture

• Prevailing NHS culture blame and punishment.
• Person-centred approach to adverse events.
• Dominance of professional silos.

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Capacity

• No one organisation with authority and
  responsibility for learning from adverse events
• Over-worked staff including clinical governance
  and risk staff

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Patient Safety A global issue
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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
• gt450 million clinical negligence settlements
• over 1 billion spent on hospital associated
  infections
• 29 million direct costs related to staff
  suspension

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Background

• Organisation with a Memory
• Building a Safer NHS

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• NPSA
• established July 2001
• special health authority
• 400 staff
• no regulatory powers

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NPSAs objectives

• 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 delivery.
• Where risks are identified, produce solutions to
  prevent harm, specify national goals and
  establish mechanisms to track progress.

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Purpose of the 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 care

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Seven steps to patient safety

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

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Step 1 - Build a safety culture that is open and
fair

• Safety is considered in everything you do
• When things go wrong you ask why and not who
• Safety is integral to improving patient care
• Staff and patients are involved
• Senior management visibly commitment to safety
• Clear accountability and responsibility
• Focus on human factors and systems approach

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Patient safety e-learning programmes
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Incident Decision Tree
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Step 2Leadership 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
• Board involvement

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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

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What is Risk Assessment?

• Application of risk assessment tools from other
  high risk industries to healthcare

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Hospital at Night (HaN) Risk Assessment Guide

• Presents an approach to risk assessing Hospital
  at Night solutions

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The Assessment Process
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Record Sheet
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Step 4Promote 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)

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How the NRLS will improve Patient Safety
standard reports
dataset
NRLS
ad hoc reports
other data sources
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Air safety reports volume risk
total
high risk
9000
3.0
8000
2.5
7000
6000
2.0
5000
1.5
4000
3000
1.0
2000
0.5
1000
0.0
0
1994
1995
1996
1997
1998
1999
year
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SAS 3D Bar Chart
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Autonomy Cluster Map
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Patient Safety Observatory

• Research development information

NRLS Data
Patient Safety Knowledge
Other data sources
National reports and organisations
Epidemiology
Local Patient Safety Information
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Step 5Involve and communicate with patients and
the public

• Initiatives
• Being Open
• Ask about medicines leaflets
• SPEAK UP
• Involve in investigation

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Step 6 Learn and share safety lessons

• NPSA Root Cause Analysis Programme

• Over 6000 NHS staff trained in RCA methodology
• E-learning toolkit
• Guidance
• Aggregated themed RCA
• RCA data capture possibilities
• Training for independent investigations

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Step 7Solutions 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 errorTelling people
  to be more careful doesnt work

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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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• 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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• Design out the problem(design solution)

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Improving Labelling and Packaging
A partnership with UK manufacturers of
Methotrexate to develop novel packaging designs
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Change the system - Crash Call Survey27
different numbers used in Hospitals across
England.
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• NPSA Patient Safety Alert 1
• Preventing Accidental Overdose with Intravenous
  Potassium
• NPSA Patient Safety Alert 2
• Standardisation of Cardiac Arrest Tel Numbers

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Involve Patients

• Hand Hygiene Project (318 patient interviews)
• 71 state that patients and the public should
• be involved in helping to improve hand
  hygiene

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To err is Human To cover up is unforgivable To
fail to learn is inexcusable
Sir Liam Donaldson Chief Medical Officer, England