working towards a national surveillance system for patient safety the national reporting and...
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Working towards a national surveillance system for patient safety
The National Reporting and Learning System and the Patient Safety Observatory
Sarah ScobieHead of Observatory
National Patient Safety AgencyUK
To err is human
To cover up is unforgivable
To fail to learn is inexcusable
Sir Liam DonaldsonChief Medical OfficerEngland
Purpose of the NPSASpecial health authority with mandate to:
– implement a national reporting system for patient safety incidents
– collect and appraise information to promote patient safety
– provide advice and guidance and monitor its effectiveness
– promote research which contributes to patient safety
– report and advise Ministers on matters affecting patient safety
Overview
• The National Reporting and Learning System• The Patient Safety Observatory: what is it and why
do we need it?• The Observatory work programme
The National Reporting and Learning System (NRLS)
• Confidential reporting database• Incidents are reported electronically – 99% come
from Local Risk Management System• Analysis of data at national level to
– identify trends and patterns– provide feedback for local action– inform NPSA work programmes
Number of incidents and reporting trusts
Approaches to analysis of NRLS data
• Routine monitoring reports• Thematic analysis• Ad hoc analysis• Exploratory
– Reviews of selected incidents– Data mining
Routine and thematic reports• Trust feedback reports• Quarterly overview• Thematic reports
Ad hoc analysis• Requests from NHS clinicians and risk managers, and relating to
current NPSA projects• Use of categorical data supplemented by sophisticated text searching
tool
• Examples during one week:– epidurals, following fatal incident, to inform an NPSA fast track
project on epidural infusions– chairs, for an external enquiry– Midwifery and Obstetrics, for Litigation Authority event on maternity
risk management– screening tests for Down's Syndrome, following software issue
identified in a trust– systemic dermatology treatments– blood glucose monitors, following issue identified by the regulator
for medical devices– wrong route administration of oral liquid medicines, to support the
preparation of a patient safety alert
Systematic review of incidents
• Richness of NRLS data in free text descriptions review from clinical perspective adds value
• Huge volumes of data – sampling by specialty and incident type
• Tools to support robust and consistent review of data supported by guidance decision tree for follow-up action
Data-mining
• Pattern-search– Looking for small localised patterns in the data– Able to look through high-dimensional data (categorical and free text)– Able to pick out small unknown patterns that may represent a trend in patient safety
• Model building and hypothesis testing
Why do we need a PSO?
• Incident data not the only source
• Systematic surveillance and analysis of NRLS and other data
Settings of incidents reported to the NRLS
Care setting Total Percent
Acute/general hospital 441,519 72.2
Mental health service 86,697 14.2
Community nursing, medical and therapy service (including community hospital)
57,029 9.3
Learning disability service 19,534 3.2
General practice 2,636 0.4
Ambulance service 2,356 0.4
Community pharmacy 1,373 0.2
Community and general dental service 179 < 0.1
Community optometry/optical service 8 < 0.1
Total 611,331 100.0
Source: Reports in the NRLS database up to 31 March 2006
Trend in reporting rates with time since connection to NRLS
5 10 15
Number of months live
0.00
0.05
0.10
0.15
Mean n
um
ber
of in
cidents
per
100 b
ed
days
EVALUATION
OTHER ORGANISATIONS
NHS Feedback
& Bounceback
PATIENTS/
PUBLIC
PRIORITISATION
R&D
Intelligence- Healthcare Commission - Expert Groups- Patient/Public - DH/Ministers- Interest Groups etc.
Research
Patient Safety Research
Other confidentialreporting systems
Other datasets.• Clinical negligence • MHRA• Hospital Episodes• GP Databases
NRLS
Public/PatienteForm
Surveillance & Monitoring
OBSERVATORY
SOLUTIONS
The Patient Safety Observatory at Work : MRI scanners
• NRLS data: 500 reports; 31 related to implants; five pacemakers, one implantable defibrillator, one heart valve and three aneurysm clips went undetected
• PSO: Litigation relating to pacemaker/MRI fatality; 200 incidents reported to medical device regulator; local visits:
• frontline staff depending on constant vigilance rather than safer systems
• Prioritisation process: report to NPSA Board this month
PSO at work: collaboration with other organisations
• Hospital episode statistics – developing patient safety indicators based on AHRQ
• Clinical negligence: NHS Litigation Authority and medical negligence organisations
• Safety culture and processes: NHS staff survey
• replicate AHRQ analysis for a sub-set of indicators
• mapping coding definitions to ICD10/OPCS4
• age and sex standardised indicators derived at national and trust level, as per specifications
• validation: length of stay and mortality (cases compared with matched controls)
• comparison with US results
Indicators from administrative data
Preliminary results: rates per 1000 discharges
Indicator England US
Death in low mortality DRGs 0.7 0.7
Decubitus ulcer 5.7 24.7
Iatrogenic pneumothorax 0.2 0.8
Infections due to medical care 0.1 2.3
Postoperative hip fracture 0.2 0.3
Postoperative sepsis 16.3 11.8
Assisted delivery 45.3 237.8
Unassisted delivery 21.7 86.2
Caesarean delivery 2.0 5.6
Preliminary results: excess length of stay (days)*
Indicator England US
Death in low mortality DRGs - -
Decubitus ulcer + 11 +4
Iatrogenic pneumothorax +6 +4
Infections due to medical care + 11 +10
Postoperative hip fracture + 23 +5
Postoperative sepsis + 13 +11
Assisted delivery + 0.6 +0.1
Unassisted delivery + 0.5 +0.1
Caesarean delivery + 0.2 +0.4* Cases vs matched controls
Patient Safety Observatory - summary
• Systematic analysis• No one source of data is sufficient• Collaboration between relevant organisations• Results:
– Investigating and reporting back– Better use of existing data– Path to integrated approach to patient safety
surveillance
