The Work of the National Patient Safety Agency

Joan Russell

Safer Practice Lead-Emergency Care

Overview

• Patient safety – what, why and how big is the problem?

• Seven steps to patient safety and the tools to make a difference

• Ambulance Service Risk Assessment

Patient Safety – A global issue

0

2

4

6

8

10

12

14

16

18

% of acute admissions

USA 3.7%

Australia 16.6%

England 10.8%

Denmark 9%

New Zealand 12.9%

Canada 7.5%

Japan 11%

Cost of unsafe care each year in the UK…

• 10% of admissions = 900,000 patients affected

• around £1 billion/year in extra hospital stay costs

• average 8.5 extra bed days

• 400 people die or are seriously injured in incidents involving medical devices

• >£450 million clinical negligence settlements

• over £1 billion spent on hospital associated infections

• £29 million direct costs related to staff suspension

Background

• An organisation with a memory

• Building a safer NHS for patients

Seven Steps

1. Build a safety culture that is open and fair

2. Lead and support your staff in patient safety

3. Integrate your risk management activity

4. Promote reporting

5. Involve patients and the public

6. Learn and share safety lessons

7. Implement solutions to prevent harm

Step 1 - Build a safety culture that is open and fair

• Safety is considered in everything you do

• There is a balanced approach when things go wrong - you ask why and not who

• Constant vigilance

PATIENT SAFETYINCIDENT

Any unintended orunexpected incident(s)

which could have ordid lead to harm for

one or more personsreceiving NHS

funded care

NO HARM

LOW

MODERATE

SEVERE

DEATH

Not prevented,but resulted in

no harm

Prevented, i.e.not impacted onpatient (previous

near miss)

NPSA Definitions

Patient safety e-learning programmes

• the perfection myth

– if we try hard enough we will not make any errors

• the punishment myth

– if we punish people when they make errors they will make fewer of them

Incident Decision Tree

Step 2Leadership and support

Leadership advised to:• Undertake executive walkabouts• Develop team safety briefing and debriefing • Appoint patient safety clinical champions• Undertake safety culture and team culture

assessments

Step 3 - Integrated risk management• all risk management functions and information:

–patient safety, –health and safety, –complaints, –clinical litigation, –employment litigation, –financial and environmental risk

• training, management, analysis, assessment and investigations

• processes and decisions about risks into business and strategic plans

Step 4Promote reporting

• National reporting and learning system (NRLS)• Reporting via:

– local risk management systems– E-form on NHS net– E-form on www

• Anonymous (names of patients and staff)• Confidential (names of organisations)

National reporting and learning system

NHS

NRLS

identification of issues prioritisation of solution work

design solution

test & implement solution

Improved patient safety

monitor impact

reports

Step 5Involve and communicate with patients

and the public

Being Open

Ask about medicines leaflets

SPEAK UP

Involve in investigation

Step 6 Learn and share safety lessons

• NPSA Root Cause Analysis Programme

• Over 5000 NHS staff trained in RCA methodology

• E-learning toolkit

• Guidance

• Aggregated themed RCA

• RCA data capture

• Training for independent investigations

Step 7Solutions to Prevent Harm

• Address root causes• Make designs of equipment, systems, processes,

more intuitive• Make wrong actions more difficult• Make incorrect actions correct• Make it easier to discover error

“Telling people to be more careful doesn’t work”

Ambulance Service Risk Assessment

• To identify existing risks at each stage of the emergency response process

• To identify possible risk solutions for high risk issues• Develop a solutions programme of work

Process

• Identification of risks• Identification of causes, consequences and controls • Prioritisation of risks• Identification of solutions• Re-evaluation of risk• Cost/time effectiveness

Key Themes

• Prioritisation/triage• Health Care Associated Infection• Managing Demand• Transfer of Care• Equipment Design

Patient safety observatory and prioritisation processPatient

Safety Info

PSO

NRLS and

other data

sources

Filtering of submissionsNPSA Board

NPSA work programme

submissions

Expert Advisory Panel

John R. Grout

How would you operate these doors?

BA C

Affordances

Push or pull? left side or right? How did you know?

Which dial turns on the burner?

Natural Mappings

Stove A

Stove B

What Can Be Done to Remove Problems ?

• Design out the problem • Change the system • Change practice • Train the staff• Involve patients

• Design out the problem(design solution)

Clear design

Case Examples

Cleanyourhands campaign

Forms of NPSA advice

• A patient safety alert requires prompt action to address high risk safety problems

• A safer practice notice strongly advises implementing particular recommendations or solutions

• Patient safety information suggests issues or effective techniques that healthcare staff might consider to enhance safety

1st team of engineers…

Task-‘replace centre console light panel around the throttle quadrant’

• Throttle levers in full power position

• Take-off warning horn silenced

• Circuit breaker pulled

Next engineer…

Task-‘trouble shoot a reported engine oil quantity discrepancy’

Requirement of task-undertake an engine run

Guidance-’Pre Power On’ Taxi/Towing Checklist

• Check circuit breakers

• Throttle levers to idle

• Parking break set

To err is humanTo cover up is unforgivable

To fail to learn is inexcusable

Sir Liam Donaldson

Chief Medical Officer

England

Thank you for listening

Any questions?

Need help contact; www.npsa.nhs.uk