The Patient Safety Challenge in the UK

Dr Kevin Cleary

Medical Director

National Patient Safety Agency

The National Patient Safety Agency

• Set up in 2001 to promote patient safety in the National Health Service in England and Wales

• Three divisions:• Patient Safety• National Clinical Assessment Service• National Research Ethics Service

Reducing risk to patients

• Work with other health organisations nationally and internationally

• National reporting system for patient safety incidents

• Recommendations for healthcare staff and organisations

National Reporting and Learning System• First comprehensive national reporting

system for patient safety incidents• All NHS organisations connected• Local to national reporting• Patient Safety Observatory: using other data

and information sources

Incident data

• Total number of incidents reported: 1,668,427 (up to end of June 2007)

• Between April and June 2007, 242,595 incidents reported

• Most incidents reported electronically via local risk management systems (approx 98%)

Patient safety incidents reported to the NPSA, November 2003 to June 2007

Reported incidents, by type, April 2006 to March 2007

Slips, trips and falls

• Patient accident most frequently reported incident type

• Falls can lead to distress, pain, injury and loss of independence

• NPSA recommendations include:• Local analysis of contributing factors• Creation of falls prevention groups• Appropriate guidance for staff, particularly in relation to

use of bed rails

Medication safety

• Second most commonly reported incident type• Each hospital in England and Wales administers

approximately 7,000 medicine doses each day.• Analysis of 60,000 medication incidents to identify

settings, groups of patients and particular medicines

Medication safety

• Types of medication incidents:• Wrong dose, strength or frequency• Omitted medicine• Wrong medicine• Wrong patient• Wrong formulation• Wrong route

Medication safety

• Patients at particular risk of medication incidents:• Patients who are allergic• Children• Patients moving across care settings• Patients cared for outside of normal processes,

e.g. out-of-hours

Medication safety

• Recommendations on:• Anticoagulant therapy• Liquid medicines via oral or other enteral routes• Injectable medicines• Epidural injections and infusions• Paediatric intravenous infusions

Medication safety

• Design of medicine packaging• Estimated that a third of medication errors caused

by confusion over packaging and labelling instructions

• Design solutions/recommendations to enhance safety

• Recommendations on dispensing packaging and dispensing environments to be published late 2007

Care setting of incident reports, April 2006 to March 2007

Care setting of incidents

• Most incidents reported occur in hospitals (approx 73%)

• Well-established reporting culture in acute sector• Most healthcare provided in the community• Need to improve reporting culture in community

settings such as general practice and pharmacy

Ambulance work

• Recommendations to improve safety in ambulance services:• Increased consistency in equipment,

consumables and layout• Standardisation of design of vehicles and

equipment• Standardised fleet – three core vehicle types

Mental health services

• Analysis of 45,000 reported mental health incidents• Particular safety issues in this sector:

• Patient accidents• Disruptive, aggressive behaviour• Sexual safety• Self-harm and suicide• Absconding and missing patients• Medication

Reported degree of harm to patients, April 2006 to March 2007

Safer care of the acutely ill patient

• Analysis of 107 patients whose deaths in acute hospitals in one year were reported

• Key issues:• Deterioration not recognised or not acted upon• Resuscitation after cardiac arrest

Improving care of the deteriorating patient• Report due out in November 2007• Analysis of incidents revealed key themes:• Lack of observation• Lack of recognition• Delay in patient receiving medical attention

Current priorities

• Four major areas of works:• Anaesthetics care• Neo-natal care• Radiology/radiography involving cancer treatment• Obstetric intra-partum care

• Review of reporting system• cleanyourhands campaign• Patient Safety Campaign

Review of reporting system

• Increasing reporting across all settings• Greater commitment by clinicians and senior

management• Rapid response process for priority issues,

e.g. reports on:• Dealing with haemorrhage• Confusion between drug names

cleanyourhands campaign

• All hospital trusts in England and Wales signed up to the campaign

• 3rd year of the 4 year campaign to improve hand hygiene

• Multi-modal approach:• Alcohol handrub• Promotional materials to raise awareness• Tools and resources to aid local implementation

• Currently being piloted in settings outside of hospitals

Patient Safety Campaign

• Clinical engagement• Management support• National campaign to raise awareness• Focusing on key issues to improve safety• Markers for organisations to measure

success against

Future challenges

• Population of 60 million, complex healthcare system

• Cultural shift• Embedding patient safety