The Work of the National Patient Safety Agency

1. The Work of the National Patient Safety Agency Joan Russell Safer Practice Lead-Emergency Care

2. Overview • Patient safety – what, why and how big is the problem? • Seven steps to patient safety and the tools to make a difference • Ambulance Service Risk Assessment

4. Patient Safety – A global issue

7. 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 • >£450 million clinical negligence settlements • over £1 billion spent on hospital associated infections • £29 million direct costs related to staff suspension

8. Background • An organisation with a memory • Building a safer NHS for patients

9. Seven Steps 1. Build a safety culture that is open and fair 2. Lead and support your staff in patient safety 3. Integrate your risk management activity 4. Promote reporting 5. Involve patients and the public 6. Learn and share safety lessons 7. Implement solutions to prevent harm

10. Step 1 - Build a safety culture that is open and fair Safety is considered in everything you do There is a balanced approach when things go wrong - you ask why and not who Constant vigilance

11. Prevented, i.e. not impacted on patient (previous near miss) NO HARM Not prevented, but resulted in no harm LOW MODERATE SEVERE DEATH NPSA Definitions PATIENT SAFETY INCIDENT Any unintended or unexpected incident(s) which could have or did lead to harm for one or more persons receiving NHS funded care

12. Patient safety e-learning programmes

13. the perfection myth • if we try hard enough we will not make any errors • the punishment myth • if we punish people when they make errors they will make fewer of them

14. Incident Decision Tree

15. 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

16. 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

17. 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)

18. reports monitor impact Improved patient safety test & implement solution design solution identification of issues prioritisation of solution work National reporting and learning system NHS NRLS

19. Step 5Involve and communicate with patients and the public Being Open Ask about medicines leaflets SPEAK UP Involve in investigation

20. Step 6 Learn and share safety lessons • NPSA Root Cause Analysis Programme • Over 5000 NHS staff trained in RCA methodology • E-learning toolkit • Guidance • Aggregated themed RCA • RCA data capture • Training for independent investigations

21. 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 error“Telling people to be more careful doesn’t work”

22. Ambulance Service Risk Assessment • To identify existing risks at each stage of the emergency response process • To identify possible risk solutions for high risk issues • Develop a solutions programme of work

23. Process • Identification of risks • Identification of causes, consequences and controls • Prioritisation of risks • Identification of solutions • Re-evaluation of risk • Cost/time effectiveness

24. Key Themes • Prioritisation/triage • Health Care Associated Infection • Managing Demand • Transfer of Care • Equipment Design

25. submissions NPSA work programme NPSA Board Expert Advisory Panel Filtering of submissions Patient safety observatory and prioritisation process Patient Safety Info PSO NRLS and other data sources

26. How would you operate these doors? Affordances Push or pull? left side or right? How did you know? A C B John R. Grout

27. Which dial turns on the burner? Natural Mappings Stove A Stove B

28. What Can Be Done to Remove Problems ? • Design out the problem • Change the system • Change practice • Train the staff • Involve patients

29. Design out the problem(design solution)

30. Clear design

31. Case ExamplesCleanyourhands campaign

35. Forms of NPSA advice • A patient safety alert requires prompt action to address high risk safety problems • A safer practice notice strongly advises implementing particular recommendations or solutions • Patient safety information suggests issues or effective techniques that healthcare staff might consider to enhance safety

36. 1st team of engineers… Task-‘replace centre console light panel around the throttle quadrant’ • Throttle levers in full power position • Take-off warning horn silenced • Circuit breaker pulled

37. Next engineer… Task-‘trouble shoot a reported engine oil quantity discrepancy’ Requirement of task-undertake an engine run Guidance-’Pre Power On’ Taxi/Towing Checklist • Check circuit breakers • Throttle levers to idle • Parking break set

42. To err is humanTo cover up is unforgivableTo fail to learn is inexcusable Sir Liam Donaldson Chief Medical Officer England

43. Thank you for listening Any questions? Need help contact; www.npsa.nhs.uk