Why Safety Matters

1. Why Safety Matters Kate Beaumont Patient Safety Strategy Advisor, National Patient Safety Agency and Public Governor, Salisbury NHS FT Catherine.beaumont@npsa.nhs.uk www.npsa.nhs.uk

2. About the NPSA What we are: • Arm’s Length Body of the Department of Health • Organised as three Divisions with distinct functions: • National Clinical Assessment Service (NCAS) • National Research Ethics Service (NRES) • Patient Safety Division (PSD) Our vision: • to lead and contribute to improved, safe patient care by informing, supporting, and influencing organisations and people working in the health sector.

3. Why is patient safety important? • Unsafe care: • significant source of patient morbidity and mortality • major cause of distress to patients and families • Safer care: • more than just a by-product of well educated, well intentioned clinicians

5. HAZARDOUS REGULATED ULTRA-SAFE (>1/1000) (<1/100K) 100,000 Health Care Driving 10,000 1,000 Scheduled Airlines Total lives lost per year 100 European Chemical Mountain Railroads Manufacturing 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

6. Risky business Potentially an average of 7,300 patients per year per hospital suffer an adverse event Double decker bus seats 73 people 100 bus loads of patients per hospital per year Almost 2 bus loads per week per hospital

8. How safe are our systems?

9. So…where are we now?

10. Reporting culture

12. The response system is more important than the reporting system

13. www.npsa.nhs.uk

14. Seven Steps to Patient Safety 1. Safety culture • Lead & support staff 3. Integrated risk management 4. Promote incident reporting 5. Involve patients and the public 6. Learn and share lessons • Implement solutions www.npsa.nhs.uk/sevensteps

15. Step 1: Build a safety culture "The feature that distinguishes the best health organisations is their culture." Sir Liam Donaldson, Chief Medical Officer, writing in BMJ 1998; 317:61-5.

16. What is a safety culture? • Safety is considered in everything you do and there is a balanced approach when things go wrong - you ask why and how • Constant vigilance - always alert to expect the unexpected • Staff understand what they should do when things do go wrong • Staff are open to and make, suggestions for • change and improvement • They believe their actions make a difference to themselves and to others

17. Maturity Levels 5. Risk management is an integral part of everything that we do 4. We are always on the alert for risks that might emerge 3. We have systems in place to manage all identified risks 2. We do something when we have an incident 1. Why waste our time on safety?

18. Culture…. The Medical Director sent a letter to all medical staff reassuring them that any error they promptly reported would be exempt from disciplinary procedures unless there was malice or blatant recklessness.

19. In the same week…. the Nurse Director sent a letter to all nurses reminding them that if they in the course of their career at the trust report a second drug error, they could expect a final warning. On the third drug error, they would be suspended and may be dismissed.

20. National Reporting and Learning System

21. An NHS Patient Safety Campaign - Inspiring Action In consultation with

22. Problem to be solved • Inspiring staff to make care as safe as possible • Not accepting ‘complications’ Reliable implementation nationally of proven practices • Making safety ‘real’ for frontline clinicians • Visible local leadership

23. The campaign cause and aim The cause To make the safety of our patients everyone’s highest priority The aim To build a culture of ‘no avoidable death, no avoidable harm’

27. Interventions: ‘development areas’ • Risk of harm from falls • Risk of harm from Venous Thrombo-Embolism • The surviving Sepsis Bundle • Peripheral lines

28. Safer Patients Initiative

29. What is the safety culture in your trust? How can you as a governor assure yourself that safety is the highest priority in your trust? What questions do you need to ask?

30. Group work!MaPSAF

32. www.npsa.nhs.uk Thank you for listening

33. DiscussionFor more information -