National Patient Safety Agency

1
National Patient Safety Agency

• Suzette Woodward
• Senior Strategic Advisor
• National Patient Safety Agency

2

• The National Patient Safety Agency was expected
  to
• collect and analyse information through a
  national reporting and learning system
• assimilate other safety-related information from
  a variety of existing reporting systems
• learn lessons and produce solutions

3
(No Transcript)
4
Challenges
Local cultures, capacity and capability
Poor data quality and limited reports from
certain areas
Lack of feedback
Multiple systems for reporting different
incidents for different purposes
Lack of consistency standardisation of approach
locally
5
Number of safety incidents reported to the
NPSAOctober 2003 June 2007
6
Reporting in Numbers
21,985 The number of incidents which are likely
to be categorised by reporters as severe or death
(based on 1.3)

• 1,691,158
• Total number of incidents reported to the NRLS
  since November 2003

12,360 Highest number of reports from one Acute
Trust (Oct 06-March 07)
1,773 Average number of reports from Acute Trusts
(Oct 06-March 2007)
Mental Health 14
430 Number of Trusts connected to the NRLS (100)
Other
274 Average number of reports from PCOs (Oct
06-March 2007)
104 The average number of days for a serious
incident to be reported through to the NRLS
Acute Sector 72
7
(No Transcript)
8
Outputs

• Published 5 patient safety observatory reports
• Disseminated 25 publications to alert, provide
  notice, rapidly inform
• Helped prioritise activity and supported the
  development of over 50 solutions for change
• But ..it has taken too long for reports of
  serious harm and death to be submitted
  nationally, as well as analysed and learning
  disseminated quickly

9
(No Transcript)
10
Outputs
11
(No Transcript)
12
What the service wants

• Build on what we have
• Quicker feedback
• recognise different audiences with different
  information needs
• Single route of reporting wherever possible

13
Conceptual Framework
Local learning of national interest
High Priority Reports

Quality assured, national trend data
14
Rapid Response

Risk of confusion between cytarabine and
liposomal cytarabine (Depocyte)
Please circulate this advice to all relevant staff
15
Looking forward

• A national response centre/call centre
• Easier to report
• Streamline reporting (MHRA, SUIs, local)

16
Future Proposal for Patient Safety Action Teams
17
Composition

• The PSATs will be a fully integrated function
  across the SHA health economy
• Patient safety action teams will consist of core
  personnel and draw on a range of skills and
  knowledge and personnel from across the patch
• Because progress on patient safety requires
  concerted action from a wide range of players, it
  is expected that PSATs will establish and become
  part of active collaborative networks including
  other national orgs within their local patch
• Each would be underpinned with quality
  intelligence, information and analysis

18
Patient Safety Delivery

• PSATs will work in the geographical patch of each
  SHA 50 of their activity would be driven by
  specific local needs and 50 driven by local
  delivery of national initiatives
• PSATs would be expected to develop an agreed set
  of local safety priorities for action drawing on
  NRLS and other sources of safety data
• The NPSA will work with PSATs to agree national
  priorities for local delivery in the areas of
  incident reporting, analysis, response and
  investigation and implementation of safer
  practices

19
PSAT key functions

• Support the local, regional and national approach
  to patient safety
• Build local capacity and capability in incident
  reporting, analysis, response and investigation
  and implementation of safer practices
• Work with the NPSA to look at how analysis and
  feedback from the existing National Reporting and
  Learning System can be more accessible and better
  inform local priority setting
• Lead performance improvement in patient safety at
  a local and regional level
• Provide local to national links as part of a
  coordinated network of patient safety action teams

20
A Coordinated Network

• The NPSA will establish a coordinated national
  network to bring together representatives from
  each patient safety action team
• The network will be for knowledge exchange and in
  particular sharing lessons, ideas and innovations
  from local to national
• At least one meeting of this network will occur
  in Phase 1

21
Principles

• The PSATs are a fully integrated function
  delivering a service locally
• The resource is available for and readily sought
  by all organisations including Foundation Trusts
  within the NHS
• The function is not perceived to be closely
  aligned with performance management and is set up
  to assist with performance improvement

22
A Patient Safety Campaign for the NHS Inspiring
Action

• In consultation with

23
Safety First

• National patient safety campaign-focused
  initiative
• Engage, inform and motivate clinical staff and
  healthcare providers to provide safer healthcare
• NPSF to oversee design and implementation

24
Vision

• Deliver for the people of England a two year
  campaign which will
• Save lives
• Reduce harm
• Implement what we already know works

25
Clinical staff interventions
26
What are we asking organisational leaders to do?
27
Thank you for listening

• Suzette Woodward
• National Patient Safety Agency