Safer Systems for a Safer NHS

1
Safer Systems for a Safer NHS

• Dr. Maureen Baker CBE DM FRCGP
• National Clinical Lead for Patient Safety
• NHS Connecting for Health

2
NPSA Report

• Commissioned 2004 by Deputy Chief Medical Officer
  (DCMO)
• Conducted by NPSA Risk Advisor

3
Report Findings

• Not identifying safety as a benefit to drive the
  programme
• No formal risk assessment
• No formal safety management system
• Reliance on clinicians to instinctively address
  patient safety problems

4
Report Conclusion

• NPfIT not addressing safety in structured,
  pro-active manner and other safety critical
  industries would

5
Action Taken

• Appointment of National Clinical Safety Officer
  (seconded from NPSA)
• Implementation of Clinical Safety Management
  System (CSMS)
• Adoption of principles of IEC 61508
• Patient Safety Assessment
• Safety Case
• Safety Closure Report
• Accredited clinician training
• Governance Structure
• Clinical Safety Group (fortnightly)
• Clinical Risk and Safety Board (quarterly)

6
On-going work

• Safer IT products
• Safety Incident Management Process
• Clinical Risk Reduction
• Safer Implementation

7
Safer IT Products

• Clinical risk management system administered
  through Clinical Safety Group
• Required documentation
• Certificate of Authority to Release (CATR)

8
Safety Incident Management Process

• Incidents identified through NHS CFH Service
  Management
• Safety incident if there is potential for patient
  to be harmed - managed by CSG
• Aim is to assess and make safe within 24 hours
• Agree fixes (risk-assessed if necessary) and
  identify lessons to be learned
• Hand back to Service Management

9
Logging a Safety Incident

• User identifies a potential safety incident
• User logs incident with relevant Service Desk
  marked as a Clinical Safety
• Incident
• Via the NHS CFH Service Bridge the NIC Safety
  Helpdesk are made
• Via the NHS CFH Service Bridge the NIC Safety
  Helpdesk are made aware of
• the Patient Safety Incident
• Safety Engineer triages incident details,
  assesses whether escalation and clinical
• assessment is required
• CSO / subject matter clinician contact for
  assessment and next steps
• Mitigations are put in place to make the
  incident safe and long-term fixes are
• scheduled passed back to service
• Long term fix is developed, tested and
  implemented by supplier, user tests and

10
Safety Incident Supporting Resources

• 4 On call Safety Engineers offering 24 hour
  support, 365 days / year
• Ian Harrison (Chief Safety Engineer)
• NIC Safety Helpdesk supporting 0800 till 1800
  Mon -Fri
• Mail - safety.incident_at_nhs.net
• Telephone - 0113  397 3033
• 4 Safety Officers (Active senior clinicians)
• Professor Michael Thick (NHS CFH Chief Clinical
  Officer)
• Dr. Maureen Baker CBE (NHS CFH National Clinical
  Lead for Safety)
• Cluster PACS Clinical Leads
• Choose Book Clinical lead
• Pharmacy / ETP specialists
• Supplier Clinical Leads - CSC / BT London /
  Accenture PACS

11
Safety Incidents to Date

• Since October 2005 226 safety incidents logged
  with NIC Safety Helpdesk e.g.
• PACS / RIS digital imagine issues
• Drug mis-mappings
• Personal Demographics (PDS)
• Network performance
• Choose Book issues, low SIL rating

12
Clinical Risk Reduction

• Right patient right care (safe management of
  blood products NHS number, wristband dataset)
• Safer prescribing (alerts top 10 unsafe drugs)
• Safer handover (scoping dataset development)

13
Safer Implementation

• High-level strategy
• Safe implementation toolkit
• Training and networking for safety

14
Recent Developments

• Appointment of Chief Clinical Officer
• Development of new Health IT Standard
• Issuing of CCCN 0061
• Development of patient safety policy
• Refinement of safety incident management process
  and procedure

15
Second NPSA Report (2006)

• Major findings
• Pro-active actions and progress made by NHS CFH
  to put in place systems and processes to address
  patient safety in the NPfIT in an explicit,
  proactive, structured and robust manner
• Gaps (opportunities for further improvement)
  where further development will enhance the
  effectiveness and efficiency of the NPfIT helping
  the NHS realise patient safety benefits
• Recommendations for NHS CFHs consideration,
  aimed at realising the opportunities for
  improvement identified
• On-going improvement opportunities

16
Conclusion

• Considerable movement from standing start 2
  years before
• Major workstreams underway
• Still early days
• Nevertheless, probably world leading work on
  safety in Health IT