Upload File

‘passionate about patient safety’ delhi – november …...national patient safety agency,...

  • Home
  • Documents
  • ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
30
Professor Sir Terence Stephenson BSc (1st class Hons), BM, BCh, DM, FRCP, FRCPCH, SFFMLM, Hon FRACP, Hon FRCPI, Hon FHKAP, Hon FRCS, Hon FRCGP, Hon FRCA, Hon FCAI, Hon FRCS Ed, Hon FRCOG, Hon FRCP Edin, Hon FAcadMEd Nuffield Professor, Institute of Child Health, University College London Consultant Paediatrician UCLH & Great Ormond Street Hospital, London Chair of the Health Research Authority for England 2019-22 Former Chair of UK GMC 2015-18 Past-President UK Royal College of Paediatrics & Child Health 2009-12 ‘Passionate about patient safety’ Delhi – November 2019

Upload: others

Post on 01-Jun-2020

4 views

Category:

Documents


0 download

Report

TRANSCRIPT

Page 1: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

Professor Sir Terence Stephenson BSc (1st class Hons), BM, BCh, DM, FRCP, FRCPCH, SFFMLM, Hon FRACP, Hon FRCPI, Hon FHKAP, Hon FRCS, Hon FRCGP, Hon FRCA, Hon FCAI, Hon FRCS Ed, Hon FRCOG, Hon FRCP Edin, Hon FAcadMEd

Nuffield Professor, Institute of Child Health, University College LondonConsultant Paediatrician UCLH & Great Ormond Street Hospital, London

Chair of the Health Research Authority for England 2019-22Former Chair of UK GMC 2015-18Past-President UK Royal College of Paediatrics & Child Health 2009-12

‘Passionate about patient safety’

Delhi – November 2019

Page 2: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

Why is this talk so relevant to India today?

The Indian government has moved towards proprietary standards for identification and traceability The need for globally harmonised standards is

crucial as healthcare becomes a global industry and the world becomes a global village I will give some positive experiences when using

them to improve patient safety Identification of pharmaceuticals also helps counter

fraud GS1 standards are one leading example of globally

harmonised standards

Page 3: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 4: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 5: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

Is the NHS safe? Of the top 20 risk factors for all deaths, adverse in-hospital healthcare

events come eleventh – above alcohol, drugs, violence and road traffic accidents.

In the NHS each year there are: 624 million prescriptions, 300 million GP visits, 13 million OPD visits, 5.3 million admissions, 2.9 million emergency ambulance calls, and an estimated 900,000 adverse events.

Every week – two wrong site surgeries and two operations with kit wrongly left inside. NEVER EVENTS 2016/17= 400

wrong site/retained foreign body/wrong implant = 79%; Medication error causing harm = 12%

Adverse events (unintended injury caused by medical management rather than disease) lead to an additional three million NHS bed days. Costing at least £1 billion a year.

Page 6: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 7: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 8: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 9: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 10: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

Wayne Jowett died following an inadvertent intrathecal vincristine injection, the 23rd such incident reported worldwide (and the 14th in 15 years in the United Kingdom)

Page 11: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 12: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

Advisor to the National Patient Safety Agency,2003-2006:

Page 13: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 14: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 15: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

Problems with identification of intravenous infusions

Page 16: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 17: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 18: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 19: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

Computerised prescribing with computerised decision support can decrease serious medication errors by 55% -64%

Page 20: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

2010 MHRA safety alert: metal-on-metal hip replacements

2010 MHRA safety alert: PIP silicone implants

Barcoding allows tracking of: PatientProduct (UDI) Place

Page 21: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 22: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 23: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 24: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

Reducing the % – worthwhile?If 99.9% were good enough…

• Major plane crash every 3 days• 12 babies given to wrong parents every day• 37,000 ATM errors every hour

Institute for Healthcare Improvement (data relate to US population)

Page 25: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 26: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY

COMBINED WITH THEEXPERIENCE OF MANY YEARS

Page 27: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing
Page 28: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

Do you want to be a patient in a hospital where safety is not taken as seriously as your next airline flight?

Page 29: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

THANK YOU

Page 30: ‘Passionate about patient safety’ Delhi – November …...National Patient Safety Agency, 2003-2006: Problems with identification of intravenous infusions Computerised prescribing

Recent Developments in Patient Safety and Scope of Patient Safety Special Interest Group Recent Developments in Patient Safety and Scope of Patient Safety

ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR … · ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR ... ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR . 2 PATIENT ... status

Patient Safety:

Patient Safety

PENNSYLVANIA PATIENT SAFETY ADVISORYpatientsafety.pa.gov/ADVISORIES/Documents/200812_home.pdf · Pennsylvania Patient Safety Advisory About the Pennsylvania Patient Safety Advisory

PATIENT SAFETY Justin MFIZI Patient Safety officer KFH

Patient Information - My Neighborhood Primary Care€¦ · medication administration, infusions, procedures, and/or services rendered to a patient by members of the medical staff,

Preparing for Brineura (cerliponase alfa) infusions · Preparing for Brineura™ (cerliponase alfa) infusions Next steps for you and your child Please see Important Safety Information

DoD Patient Safety Program Patient Safety Improvement Guide

Patient Safety Evaluation System and Patient Safety Organization Fundamentals

PATIENT SAFETY CULTURE AND PATIENT SAFETY … · 2 Patient Safety Culture and Patient Safety Implementation in Stella Maris Hospital during National Health Insurance Era Fridawaty

Introduction to Clinical Champion Training · • Total Parenteral Nutrition (TPN) • Complex pain infusions i.e.. Patient-Controlled Analgesia (PCA) and Epidural infusions • Blood

Enhancing Patient Safety and Outcomes: The Safe Patient Handling … Patient Safety... · Enhancing Patient Safety and Outcomes: The Safe Patient Handling Connection Presented by

Copyright 2007 Partners Radiology Patient Safety Training “Patient Safety in Radiology” Partners Radiology Patient Safety Team

FIXED CONCENTRATION INFUSIONS...recommended that infusions should be prepared centrally (14). This supports the recommendations from the National Patient Safety Agency (NPSA), that

Patient Safety Movement Foundation Presents · APSS #17 –Patient Safety Curriculum Patient Safety Curriculum for All Health Professionals May 8, 2019 Patient Safety Movement Foundation

PATIENT SAFETY Protecting Patient’s Right Protecting Patient’s Right General Patient Safety Measures General Patient Safety Measures Admission of the Patient

Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)