a vision: using data to ensure the safe provision of care dr bruce warner deputy director of patient...
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A vision: using data to ensure the safe provision of care
Dr Bruce WarnerDeputy Director of Patient
SafetyNHS England
International and National Recognition of Patient Safety
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1999 2000 2001
June 2012 – from the National Patient Safety Agency to the NHS Commissioning Board
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“We propose to abolish the National Patient Safety Agency”
“The work of the Patient Safety Division relating to reporting and learning from serious patient safety incidents should move to the NHS Commissioning Board…
… covering the whole function from getting evidence to working up evidence-based safe services.”
Time to Move On
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Patient safety as an essential component of quality
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““… [we all] need to place the safety of patients at the forefront of the agenda in healthcare. Safety cannot be allowed to play second fiddle to other objectives that may emerge from time to time. It is the first objective.”Sir Ian Kennedy, Chairman Healthcare Commission
Patient experience
Safety
Effectiveness
Safety is not a minimum threshold – all services can and should strive to excellence in safety
A. Why waste our time on safety?
B. We do something when
we have an incident
C. We have systems in place
to manage all identified risks
D. We are always on the alert for risks that might
emerge
E. Risk management is an
integral part of everything that we
do
PATHOLOGICAL REACTIVE BUREAUCRATIC PROACTIVE GENERATIVE
The Manchester Patient Safety Assessment Framework
NHS Outcomes framework
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The interplay between patient safety and clinical guidelines
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It is about the way we safely deliver care once the
clinical decision on how to treat has been made –
the clinical decision may be the right one but it is not
a given that we will deliver it without error.
NHS | Presentation to [XXXX Company] | [Type Date]10
Understanding the National Reporting and Learning System
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The National Reporting and Learning System (NRLS)
Local Risk ManagementSystem
Open AccessE-Forms
NHS netwww
The system collects
•all types of incidents•from all care settings•from all specialties•from all staff groups
National Reporting & Learning System
NHS Trusts
Practitioners & Staff
Patients
Carers
NRLS
CQC
MHRA
NHS Complaints
NHS Litigation Authority
International
Collaboration
Australia
USA
Europe
Sta
nd
ard
ised
rep
ortin
gCommunity Pharmacy multiples
Commissioners
PATIENT SAFETYINCIDENTAny unintended orunexpected incident(s)which could have ordid lead to harm forone or more personsreceiving NHSfunded care
NO HARM
LOW
MODERATE
SEVERE
DEATH
Not prevented,but resulted inno harm
Prevented, not impacted onpatient
NRLS definitions
Good Catch
Good Luck!
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By 31 March 2012
7,070,261 reports had been reported.
Approximately
3,700 incidents are reported to the NRLS per day.
Around 94% of incidents cause low or no harm
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Chart 1: Proportion of incidents by care setting for incidents reported to the NRLS 2010/11
NRLS limitations:very little reporting from general practice
Patient safety incidents reported to the NRLS
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All care settings: death and severe harm themes 2011/1217
Searching by keywords: example
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NICE Quality Standard for Bacterial meningitis and meningococcal septicaemia in children
Key word search for ‘mening*’ in free text of incident reports identified 182 relevant incidents, all clinically reviewed and themes summarised to inform the development of the Quality Standard
We need a trigger
NHS | Presentation to [XXXX Company] | [Type Date]20
Different solutions for different problems
Unsafeacts
Unintendedactions
Intendedactions
Skill based errorsMemory or
attention failures
Rule & Knowledge Based errors
RoutineReasonedReckless Malicious
Violations
Mistakes
Slips & Lapses
Education and training will not prevent slips and lapse or violations and we will constantly have new junior staff with knowledge gaps
Routine violations: campaigns to change culture and attitudes
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Slips and lapses: make the right thing the easiest thing to do
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Knowledge and rule based error: build in senior advice and empower patients
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Patient Safety Reports for NICE QS
Local audit data
PCT audit of vaccine storage in
GP practices shared with NPSA
Significant proportion of vaccines
stored outside recommended
temperature range
NRLS Searched
National guidance produced
NHS | Presentation to [XXXX Company] | [Type Date]26
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Rapid but robust process:• NRLS search• Threshold criteria• Literature search• Topic expert advice• Patient and carer perspective • Formal consultation (100+) • ‘Still safe and relevant?’ reviews
NHS | Presentation to [XXXX Company] | [Type Date]28
Last words
The power is in the qualitative data
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• “…called to A wing…prisoner in cardiac arrest….had attended healthcare unit yesterday complaining of indigestion, given Gaviscon, no access to previous health records (recent transfer), in hindsight probably missed diagnosis of acute coronary syndrome…….”
• “Terminally ill patient required switch to syringe driver as no longer able to take oral meds; only one community nurse on duty this Sunday for [large geographical area] and 17 urgent visits already on list; five hour delay causing much distress to patient and family”
Sepsis Report
• Whole report based on 10 case studies
• Power was not in the 37,000 deaths a year but in the human storey
Jill’s Storey
Wrong Patient
