safer systems for safer healthcare

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Safer Systems for Safer Healthcare. Dr. Maureen Baker CBE DM FRCGP Clinical Director for Patient Safety NHS Connecting for Health. Overview. The NHS The NPfIT Development of patient safety movement Safety management systems NHS CFH Clinical Safety Management System Experience so far - PowerPoint PPT Presentation


  • Safer Systems for Safer HealthcareDr. Maureen Baker CBE DM FRCGPClinical Director for Patient SafetyNHS Connecting for Health

  • OverviewThe NHSThe NPfITDevelopment of patient safety movementSafety management systemsNHS CFH Clinical Safety Management SystemExperience so farNext steps

  • The UK National Health ServiceUK population 60 MillionAlmost 1 Million consultations with GPs every working day100,000 people in hospital every working dayNHS covers every health sector4 country model750 Million prescription items from general practice in England per annum

  • The National Programme for IT in the NHS in EnglandEstablished 2002Has a number of central features and programmes (National Spine; Choose and Book; GP2GP; National Care Record Service; Picture Archive and Communications Service; Electronic Transfer of Prescriptions)Local Service ProvidersEstimated cost US$25 Billion over 10 years (contracts, training and implementation)Being delivered by NHS Connecting for Health

  • Some definitions Patient Safety freedom from accidental harm to individuals receiving healthcare

    Patient Safety Incident an episode when something goes wrong in healthcare resulting in potential or actual harm to patients

  • NPSA Report on Safety in NPfITNational Patient Safety Agency established 2001Report commissioned 2004Conducted by NPSA Risk Advisor

  • Report FindingsNot identifying safety as a benefit to drive the programme No formal risk assessmentNo formal safety management systemReliance on clinicians to instinctively address patient safety problemsNPfIT not addressing safety in structured, pro-active manner and other safety critical industries would

  • Safety Critical Industries with Safety ApproachAviationRailwaysOil and GasConstructionNuclearMilitary

  • NHS CFH Clinical Safety Management SystemBased on principles of IEC 61508Light touch, yet robustThree key pieces of documentationPractical and pragmatic in place for almost 4 yearsSupplemented by established Safety Incident Management Process

  • NHS CFH CSMS Deliverables

    Hazard assessmentSafety caseSafety closure reportClinical Authority to Release (CATR) (Includes caveats)

  • Safer Care, i.e.:x > y = a+b

    What we are trying to achieve?RiskBaker, M et al, Safer IT in a Safer NHS: Account of a Partnership, The British Healthcare Computing & Information Management, Vol. 23 No. 7 Sept 2006

  • Safety Incident Management SystemIncidents related to Health IT reported and logged Assessed and managed by Clinical Safety Group (clinicians and safety engineers)Aim to make safe (remove potential for harm) with 24 hoursAround 430 incidents reported since 200597% made safe within 24 hours

  • NHS IT What can go wrong?Patient identification (wrong notes, wrong results, wrong procedure)Data migration (re-start discontinued drugs, incorrect preservation of meaning)Data mapping (mapped to non-identical preparation, eg long-acting or slow release)Data corruption (over-writing of info on NHS Spine)

  • Safety Workstreams in NHS CFHSafe IT systems (as safe as design and forethought will allow)Safety Incident Management ProcessTraining for accreditation and safe implementationTechnology for patient safety

  • Accredited Clinician ProgrammeDedicated training in principles of safety and risk as applied to Health ITIn 4+ years trained over 550 delegates, approx 60% are cliniciansClinicians must be registered with appropriate regulatory bodySupports clinical input to activity by appropriately trained and qualified clinicians

  • Passing the Safety BatonNHS CFH (and Software Providers)

    Support from:Clinical Safety Group

    Clinical Authority to ReleaseImplementing organisation (Hospitals Pharmacists, GPs etc.)

    Support from:Internal Risk TeamSafer Design and DevelopmentSafer ImplementationPassing the Baton Ownership passed from NHS CFH to NHS

  • Implementation NetworkAimed at individuals in NHS Trusts with direct responsibility for significant IT implementationsDevelop a community of interestExplicitly designed to facilitate networking and peer supportDedicated website BuddyingCould be used in support of User Standard

  • Technology for Patient Safety Right Patient Right Care (tracking technologies RFID; wristband datasets; NHS number)Safer prescribing (prompts + alerts, tallman)Safer handover (core dataset)Electronic risk assessment tool for VTETracking of resultsDeteriorating patients

  • Design and the NHSThe NHS is seriously out of step with modern thinking and practice with regards to design . And also fails to understand what design thinking can bring to an organisation . A direct consequence of this has been a significant incidence of avoidable risk and error

    Department of Health & Design Council, Design for Patient Safety Report

  • Building a House

  • Next stepsFocus on design and human factors for inherently safe systemsSupport implementation of standards (NHS and international) for suppliers and usersPassing the safety batonIdentification and safe implementation of technology for safer care

  • National Programme for IT in NHS The National Programme is not just an IT programme, but a patient safety and clinical governance programme

    Gordon Hextall, Chief Operating OfficerNHS Connecting for Health

  • ConclusionHealthcare is a safety critical industryIT systems dont deliver care, but are used by clinicians in the delivery of careGood safety practice requires proactive work systems as safe as design and forethought will allowAlso reactive systems to detect and manage errorsAll encompassed in CSMS and within emerging Standards



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