An Introduction to the Patient Safety First Campaign for England A presentation to participating trusts

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An Introduction to the Patient Safety First
Campaign for EnglandA presentation to
participating trusts

• A statement of the problem
• The vision for the campaign
• The interventions
• The supporting resources
• What your commitment involves
• What you can do between now and registration

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A statement of the problemThe need for the
campaign

• Estimates suggest that one in ten patients in
  hospital experiences an incident which puts their
  safety at risk, and that about half of these
  could have been prevented

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A recent UK study concluded

• 8.7 of admissions had at least one adverse event
  
• (95 CI 7.0-10.4)
• .of which 31 were judged preventable
• 15 of adverse events led to impairment or
  disability which lasted gt6 months.
• 10 contributed to patient death
• Increased mean length of stay of 8 days (95 CI
  6.5-9)
• Adverse event any unintended event caused at
  least partly by healthcare and which resulted in
  harm
• Sari AB-A, Sheldon TA, Cracknell A. (2007)
  Extent, nature and consequences of adverse
  events results of a retrospective case note
  review in a large NHS hospital. Qual Saf Health
  Care 16434-9

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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
1
1
10
100
1,000
10,000
100,000
1million
10million
Number of encounters for each fatality
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The vision for the campaign

• The campaign cause is
• To make the safety of patients everyones
• highest priority
• The campaign aim is to achieve
• No avoidable death, and no avoidable harm

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What can be achieved
Adverse events
150
100
Individual Value
50
0
-50
2/28/2005
4/20/2005
6/30/2005
8/23/2005
2/16/2006
4/16/2006
6/16/2006
8/16/2006
2/16/2007
4/16/2007
6/16/2007
8/16/2007
1/16/2008
11/16/2007
10/20/2005
12/20/2005
10/16/2006
12/16/2006
Period
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What can be achieved
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The interventions

• Leadership for safety Boards on Board with
  patient safety
• Care of the deteriorating patient
• Critical care central line and ventilator care
  bundles
• Perioperative care the surgical site infection
  bundle and World Health Organisation (WHO) safe
  surgery checklist
• Reduction of harm from high risk medication
  includes anticoagulants, narcotics, insulin and
  sedatives

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Supporting resources

• Intervention how to guides containing the
  evidence base and suggestions for how to make
  improvements
• Guidance on measurement
• Global Trigger Tool training
• An extranet site for data entry/monitoring
• Teleconference and online support on a variety of
  topics relevant to the campaign
• Local support via the ongoing development of
  field teams
• Campaign website from 15th September

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What your commitment involves

• A pledge to your organisation that safety is your
  highest priority
• Agreement to work on the Leadership for safety
  intervention
• Agreement to work on at least one other
  intervention
• Undertake regular case note review using the
  IHIs Global Trigger Tool (UK version)
• Regular posting of your results from all of the
  above on the extranet site

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What your commitment involvesLeadership for
safety

• Understand your own outcomes Review and monitor,
  for example, your hospitals standardised
  mortality rate and mortality rate per specialty.
• Get the Board involved Set a Board goal for
  reducing, for example, avoidable mortality and
  adverse events, and monitor it (using the Global
  Trigger Tool).
• Provide visible leadership Talk to your staff
  via structured patient safety walkabouts.

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What your commitment involvesGlobal Trigger
Tool (GTT)

• You will need a small team of trained reviewers
  (1 doctor, 1 senior nurse, 1 clinical other. The
  other could be a doctor, nurse, pharmacist,
  Patient Safety Manager etc.
• 2 of the team review 20 randomly selected case
  notes per month. This can be done as a batch of
  20 or 10 sets every 2 weeks (3.5 - 4 hours per
  month per reviewer)
• The findings are then adjudicated and agreed by
  the Doctor in the team (2 hours per month for the
  Doctor)

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What participating trusts can do between now and
registration

• Make a pledge to your staff that the safety of
  patients is your highest priority
• Assign a key contact in the organisation to
  liaise with the campaign team and co ordinate the
  registration process. Let the campaign office
  have their name, job title and email address via
  info_at_patientsafetyfirst.nhs.uk
• Choose the other intervention(s) you would like
  to sign up for and find enthusiastic individuals
  who will test out relevant improvements in their
  areas

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What participating trusts can do between now and
registration

• In addition.
• If you already have trained case note reviewers
  but are not regularly using the GTT, start now.
  Building a picture of your baseline harm events
  which may influence your decision as to which
  intervention(s) to focus on.
• Safer Patients Initiative or Leading Improvement
  in Patient Safety sites