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The Context

The Context. Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative. Severity of incidents by care setting, April 2006 to March 2007. Some facts and figures.

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The Context

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  1. The Context • Some facts and figures • The interventions - • The World Alliance for Patient Safety • The Patients for Patient Safety initiative

  2. Severity of incidents by care setting, April 2006 to March 2007 Some facts and figures

  3. Number of patient safety incidents reported, by quarter, 10/2003 to 9/2007

  4. Reported incidents by type, July 2006 to June 2007

  5. Care setting of incident reportsJuly 2006 to June 2007

  6. Reported degree of harm to patients, July 2006 to June 2007

  7. The intervention - Working in Partnership with Patients

  8. Part of the WHO Alliance for Patient Safety Patients For Patient Safety

  9. Who are we? • Susan Sheridan* • Co-founder Consumers Advancing Patient Safety, USA (Chair) • Peter Mansell* • Director for Patient Experience and Public Involvement, National Patient Safety Agency, England and Wales • Martin J. Hatlie • President, Partnership for Patient Safety, USA • Garance Upham* • People's Health Movement, Disability and Economics Circle • Jo Harkness • Policy & External Affairs Director. International Alliance of Patients' Organizations • Helen Hughes • World Health Organisation (Secretariat) * = people who have experienced harm

  10. The aim To generate: • a patient centred approach in patient safety in health • consumer interest and networks in patient safety in/with • the Alliance’s work strands • each other • and apply a method of identifying patient safety champions

  11. The Group’s role • Defined in the statement of case • to help clinicians get the • whole picture (we are often the only people who see this) • and understand issues from a patient’s perspectives such as social and economic aspects • PFPS participating as equals; not victims. • We expect the spirit to be willing from professionals but default behaviours to mean we have to speak up!

  12. Current work • About 200 activists from around the world working • Consumer champions’ workshops in WHO regions and within countries • WHO regional offices developing patient safety strategies • Solutions products • Research • developing tools to measure harm • working with teams delivering studies • The global patient safety challenge • pilot sites • guidelines content

  13. The patient involvement landscape and experience within England

  14. Reference points • When things go wrong, [patients] and their families suffer from the harm caused. Such harm is often made worse by the defensive and secretive way that many healthcare organisations respond in the aftermath of a serious event. • Partnership must be a key theme: patients, health professionals, policymakers and healthcare leaders should be working together to prevent avoidable harm in healthcare. A particular focus is to challenge the current culture of denial. (Safety First 2006)

  15. Where can patients add value? • Sharing their insights • Offering different perspectives • Using experience for improvement

  16. Sharing insights - Anticoagulants

  17. Offering different perspectives - number of trusts that regularly report to the NRLS • October 2003 to December 2007 -2,145,606 PSIs • Of the 427 NHS organisations in England and Wales,*89% reported at least once between October to December 2007 • 57% of all NHS organisations didn’t report at least once per month

  18. Using experience for improvement - views on medication – implications for commissioning • Design • Two people reported mistakes made in the use of insulin pens, (slow-release and a quick-release), which look identical. When one person was about to go hypoglycaemic, they picked up the slow-release pen by mistake and ended up in hospital. “This is easy to do when you’re in a hurry and anxious”.

  19. Language, names and look of drugs • Several participants described how a change in the brand of a prescribed drug can create serious problems, causing confusion and increasing the risk of mistakes being made • Implications for the NHS in commissioning: • Spot market purchase brings its own set of risks when viewed by patients • Different look/Language/Names

  20. So the impact of involving patients can be to • Provide new knowledge • New ways of seeing things .. and so .. • Provide a way to reconnect with people who have lost trust

  21. The NPSA contribution to you – making space for staff and patients* • May workshop linked to the Patient Safety Congress • To foster and build collaboration and links between patients and staff on the range of patient safety efforts at regional and local levels, so that lessons can be shared and partnerships created. • Three summit events aimed at answering: • What do safe health services look like? • What do safe GP services look like? • What do safe Mental health services look like? • Autumn workshop aimed at SHA alliances/federations and patients to review work to date

  22. Formational Workshops

  23. Closing message • Patient safety • Can’t be achieved without the active involvement of patients and those close to them • Is about trust and transparency as well as reducing error and harm • Our role is to help staff and patients regionally and locally work together

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