Sue Osborn/Susan Williams Joint Chief Executive

1. Implementing Patient Safety Programmes – the story no one ever wants to tell!Expert Seminar - Paris22 – 24 May 2006 Sue Osborn/Susan Williams Joint Chief Executive

2. National Patient Safety Agency “ to improve safety of patients by promoting a culture of reporting and learning from patient safety incidents affecting patients receiving National Health Service funded care”

3. Purpose of NPSA Help the NHS to: • learn from things that go wrong • develop and implement solutions to problems • improve patient safety in frontline services Focus on: • systems not individuals • learning not judgement • fairness not blame • openness not secrecy • all care settings not just acute

4. National Health Service Northern Ireland Scotland Wales England

5. National Health Service • State funded healthcare system • 3rd largest employer in the world behind Chinese Army and Indian Rail Industry • Biggest organisation in Europe

6. UK context • Population 65 million • 560 NHS Healthcare Organisations • 2 million prescriptions every day • 360 million patient contacts over a year • 40-50 million clinical decisions per million population per year • Budget £92.6 billion ($170.3 billion) • 7% of Gross Domestic Product (US 13.6%)

7. The National Patient Safety Agency • Collect and analyseinformation on adverse events from local NHS organisations, NHS staff and patients and carers: • Assimilateother 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 organisations and delivery; • Where risks are identified, produce solutions to prevent harm, specify national goals and establish mechanisms to track progress.

8. National Reporting & Learning System electronic system to enable NHS organisations, staff and patients to report patient safety incidents to a national database links to local risk management systems

9. Source: Seven steps to patient safety: a guide for NHS Staff (NPSA) ‘any unintended or unexpected incident which could have or did lead to harm for one or more patient receiving NHS funded healthcare’ Patient safety incident

10. NRLS

11. Five levels of severity No harm Those prevented (near miss) Those that were not prevented Low harm Moderate harm Severe harm Death

12. NRLS dataset ‘What’, ‘When’, ‘Where’ … and a little ‘How’ & ‘Why’ but NOT Who notification and basic learning data hypothesis generating single high level dataset specialty extracts free text to help understanding data analysis tools flexibility over time to develop new data fields stable during national roll out

13. Overview of analysis of NRLS data • Routine monitoring reports • Thematic analysis • Ad hoc analysis • Benchmarking information for trusts • Exploratory • Reviews of selected incidents • Data mining • The Patient Safety Observatory: analysis of other data sources

14. Patient Safety Observatory • Building a memory: Preventing harm, reducing risks and improving patient safety

15. Number of incidents and reporting trusts

16. Table of incident reports by care setting

17. Table of incident reports by degree of harm

18. Total reported incident types

19. Who reports:staff type (where known)

20. Reported incident types • Acute/hospital sector • Ambulance services • Mental health • Learning disabilities • General Practice

21. Reported incident types in acute/general hospitals

22. Reported incident types in ambulance services

23. Reported incident types in mental health services

24. Reported incident types in learning disability services

25. Reported incident types in general practice

26. Turning information into learning

27. Reported incident types in acute/general hospitals

28. Acute incidents: medication process

29. Description of medication incident

30. Bench marking information: feeding back to individual organisations

31. NPSA Activity Analysis For Chief Executive, NHS Foundation Trust

32. Feedback to individual organisations • Report available to individual organisation via secure internet site • Password protected-only NHS organisations can access

33. NRLS extranet launch • New service available to all NHS organisations in England and Wales from 2 May 2006 • Each NHS organisation has their own individual report providing a comparison between their data and similar organisations over a 3 month period • Similar organisations are “clustered” in line with existing definitions • Reports to be made available quarterly

34. NHS organisation clusters • Ambulance • Mental Health • Learning Disability • Primary Care Organisations • Large Acute • Medium Acute • Small Acute • Acute Specialist • Acute teaching

41. Influencing Role

42. An Example of Influencing Role –Connecting for Health • To deliver IT systems which improve clinical safety. • To provide suppliers with an easy to use and robust safety management system. • To provide Trusts with assurance and clear guidance on the actions they need to take to ensure systems are deployed in an effective and safe manner.

43. Requirements All CfH products and every request to connect with spine must have: • End-to-end hazard assessment • Safety case • Safety closure report Must have clinical authority to deploy (issued by Clinical Safety Officer or Director of Knowledge Process and Safety) before products can be accepted into integration testing and deployment

44. Clinical Safety Organisation NHS CfH Programme Board

45. Clinical Risk Minimisation Programme of work to that allows identified safety solutions to be fed into CfH – includes • Right Patient Right Care • Safer prescribing • Safer handover As problems identified through NPSA’s Patient Safety Observatory, those with technology solutions can be fed into CfH through this work programme

46. Embedding SafetyEducational Module for Junior Doctors • Aimed at doctors in second foundation year. • Module linked to patient safety learning requirements in AoMRC’s Curriculum for Foundation Years • Educational material to be available online at www.saferhealthcare.org • Material will support clinical tutors in Trusts to deliver module

47. Content of educational module • Principles of human error • Principles of risk assessment • Safer systems • Learning from when things go wrong (including incident reporting and RCA) • Being open • Doctors Net – 39,000 interactions with online materials on patient safety

48. Solutions: preventing errors: a hierarchy Design out the potential for harm Make incorrect actions correct Make wrong actions more difficult Make it easier to discover errors

49. Preventing errors: a hierarchy Design out the potential for harm

50. Preventing Errors: a hierarchy Before After