PSSIG Scoping Session

1. PSSIG Scoping Session Chris Foye Information Architect National Patient Safety Agency, UK 28th September 2004

2. Overview • San Antonio • Revisit PSSIG’s scope • Decision tree • Ensure efficient working of PSSIG • Set priorities • Aim • Ensure paper is truly representative • Finalise paper

3. Agenda • Assumptions • Patient safety / patient safety incident definitions • Principles • Vision statement / mission statement • WHO’s International Patient Safety Alliance • Reporting systems • Prioritisation • Decision tree

4. Assumptions Goal – improve patient safety Derive PS messages which have universal applicability. No consistent view of patient safety and what constitutes a PSI Financial, resourcing and time considerations out of scope Cannot operate disconnected from the realities of modern health care

5. Patient safety & patient safety incident definitions Patient safety: • The processes by which an organisation reduces the risk and occurrence of harm to patients as a result of their healthcare Patient safety incident: • Any unintended or unexpected incident(s) that could have or did lead to harm for one or more persons receiving healthcare services

6. Principles • Provide context • Unearth assumptions about patient safety • Translate into modelling assumptions • Identify potential work streams • Activities • Prioritisation • Formulate vision statement • Mission statement • Scope

7. Modelling Assumptions Messaging Assumptions Single Reporting System Patient Safety Centre Leverage Information Sources Observatory External Factors Single Reporting System Patient Safety Centre Leverage Information Sources Observatory External Factors Clinician’s Workflow Research Programme Implement Lessons Learnt Localisation Post-Incident Investigation Clinician’s Workflow Research Programme Implement Lessons Learnt Localisation Post-Incident Investigation Principles

8. Vision statement • Ensure patients receive the safest care possible • Encourage a systemic view • Establish a message model for capturing and transmitting PSI data • Ensure complementary information is directed to the appropriate organisations: • Aid understanding • Provide context • Assist in the analysis and identification of areas of concern. • Embed patient safety related clinical decision support systems to reduce overall system risk.

9. Mission statement • Standard message model for patient safety • Facilitate reporting and investigation • Work with other SIGs • Ensure messages do not adversely affect patient safety • Decision support mechanisms • Complementary information

10. WHO’s International Patient Safety Alliance • Recognise need for international representation • PSA recognises that “…no single player has the expertise, funding or research and delivery capabilities to tackle the full range of patient safety issues on a worldwide scale. An international alliance would provide a mechanism to decrease duplication of investment and activities.” • PSSIG should work with the PSA to: • Raise awareness of the group’s activities • Disseminate key deliverables for review • Seek guidance • Ensure the needs of the international community are catered for

11. Reporting systems • Review of Central Returns Committee (ROCR) • Over 97 different requests for non-financial information. • “Year-on-year impact on the NHS of supplying non-financial data in 2000/2001 was an increase of 74 person years.” • Unnecessary burden on frontline staff • Double entry • Information silos

12. Entry point Generic Patient Safety Report M e d i c a t i o n V a c c i n e s D e v i c e s S p e c i a l t i e s I n f e c t i o n s T r a n s f u s i o n s

13. Prioritisation • Individual Case Safety Report • Generic Patient Safety Report • Sub-Domain Development • Incident Investigation • Decision Support • Complementary Information

15. chris.foye@npsa.nhs.uk