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10.8% of patients experienced an adverse eventRetrospective review of 1,014 recordsHalf of these events were preventableA third of adverse events led to moderate, or greater disability, or death. 1Adverse events in British hospitals; preliminary retrospective record review, Vincent et al BMA 2001;322; 517-9 .
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1. National Patient Safety Agency Clive Tomsett Assistant Director of Safety Solutions
2. 10.8% of patients experienced an adverse event
Retrospective review of 1,014 records
Half of these events were preventable
A third of adverse events led to moderate, or greater disability, or death
3. The estimated scale of the problem: acute sector 900,000 patient safety incidents per year across the NHS
3,000 patient safety incidents per hospital
More than 1,000 of these will have moderate to severe consequences
27,000 extra bed days
Average cost, per hospital, of Ł7.4 million
4. Patient safety: myths The perfection myth
If people try hard enough, they will not make a mistake
The punishment myth
If we punish people when they make mistakes, they will make fewer of them;
Remedial and disciplinary action will lead to improvement by channelling or increasing motivation
5. Systems approach: the ‘how’, not the ‘who’
6. Incident Decision Tree
7. Root Cause Analysis
8. About us (i) We:
were established July 2001;
are a Special Health Authority;
have been created to coordinate efforts to identify and learn from patient safety incidents.
9. About us (ii) Our objectives are to:
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 deliver;
where risks are identified, produce solutions to prevent harm, specify national goals and establish mechanisms to track progress.
10. About us (iii) Not a regulatory body
Not performance management
No disciplinary powers
Share information
Issue alerts/advice on good practice
11. Background (i) Created following the publication of:
An organisation with a memory, which looked at learning from adverse incidents in the NHS;
and
Building A Safer NHS for Patients, which set out the government’s plans to address AOWAM’s recommendations.
12. The guide (ii) Step 1 Build a safety culture
Step 2 Lead and support your staff
Step 3 Integrate your risk management activity
Step 4 Promote reporting
Step 5 Involve and communicate with patients and the public
Step 6 Learn and share safety lessons
Step 7 Implement solutions to prevent harm
13. Give own background ward sister, tissue viability nurse, assistant director of nursing, directorate manager for older peoples services across acute and community hospital settings, general and mental healthGive own background ward sister, tissue viability nurse, assistant director of nursing, directorate manager for older peoples services across acute and community hospital settings, general and mental health
14. SUIs remain separate processSUIs remain separate process
15. National Reporting and Learning System (iii) Identify and record three types of incident: those that have happened, those that have been prevented, and those that might happen
Store anonymised information which will be analysed to discover patterns and underlying contributory factors
Will be able to identify originating NHS organisation and exploring methods for providing feedback in the future
16. Safety Solutions Overview
Alerts
Wrong Site Surgery
Team Self Review
17. c) double the size of the fixtures
18.
d) etch the image of a fly on the porcelain
19. Safety Solutions (i) We have a wide range of patient safety solutions development projects underway
Once fully developed and tested, practical solutions will be shared with the service for implementation locally
We will also issue alerts with advice where we identify serious patient safety issues
21. Perceptions of ‘Wrong’ Public confidences of ‘wrong’ failures can be devastating for all involved, (professional, organisational and personal reputations)
Systems failure / communication breakdowns
22. Wrong Site Surgery covers not only surgery performed at the wrong anatomical site (incorrect finger on the correct hand), but also; Wrong patient
Wrong side (left / right)
Wrong level (spine)
Wrong operation (glaucoma instead of cataract)
Wrong implant/prostheses (hip or eye)
Wrong orientation of implant (lens implant for correct patient, site & side – but implant inverted)
23. To Mark or Not To Mark That Is The Question
27. TSR Issues Raised (21 & 23 reviews)
