An Introduction to the National Patient Safety Agency

1. An Introduction to the National Patient Safety Agency Dr. Richard Lewis Special Adviser

2. An Organisation with a Memory • Led by Professor Sir Liam Donaldson, Chief Medical Officer, June 2000 • Examining systematic learning from adverse events and service failure in the NHS • Proposed developing a culture of openness, reporting and safety consciousness within NHS organisations

3. advise Ministers promote R&D capture and analyse incidents track progress develop NHS-wide solutions assimilate information from others

4. The Reporting and Learning System • All NHS funded services to participate – notification of basic information, targeted incidents, root cause analysis • National database is anonymous (the ‘what?’ not the ‘who?’) • Expectation that PCTs will co-ordinate reporting in primary care and provide support to practitioners (e.g. root cause analysis) • All NHS staff/contractors and the public can have direct access through our website • New ‘e-form’ to simplify reporting

5. What we do not do collect names of clinicians or patients pass information to regulatory bodies such as GMC or CHI about individual cases investigate individual cases

6. What next for PCTs? • Further stage of development and testing (now until Summer 2003) • 12 PCT/LHG pilots recruited • Phased implementationacross NHS from 2003/4