patient safety thinking differently
TRANSCRIPT
Patient safety: thinking differently Exploring the challenges in patient safety improvement from national, local and personal perspectives
Frances Healey, RGN, RMN, PhDHead of Patient Safety Insight, NHS England
4 December 2014
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
Vulnerable groups
Vulnerable points of
care
Key types of harm
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
In
teg
rate
d P
ati
en
t
Safe
ty S
tra
teg
y f
or
the N
HS
www.england.nhs.uk
Around 12,000,000 incidents have
been reported.
Approximately 4,000 incidents are
reported to the NRLS per day
Around 94% of incidents cause low
or no harm
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
Oct -Dec
2003
Apr -Jun
2004
Oct -Dec
2004
Apr -Jun
2005
Oct -Dec
2005
Apr -Jun
2006
Oct -Dec
2006
Apr -Jun
2007
Oct -Dec
2007
Apr -Jun
2008
Oct -Dec
2008
Apr -Jun
2009
Oct -Dec
2009
Apr -Jun
2010
Oct -Dec
2010
Apr -Jun
2011
Oct -Dec
2011
Incidents submitted
Scale of the problem: reported incidents
• Each report an opportunity to learn: 68% no harm & 25% low harm
• But each report also represents actual or potential distress or harm to patients and concern from staff
NRLS Quarterly Data workbooks April 2012 – March 2013 England data: 1,353,430 incidents in total
Other
Patient abuse (by third party/staff)
Infection Control Incident
Medical device / equipment
Disruptive, aggressive behaviour
Self-harming behaviour
Consent, communication, confidentiality
Clinical assessment & diagnosis
Infrastructure
Documentation
Access, admission, transfer, discharge
Medication
Treatment, procedure
Implementation of care
Patient accident
0 50,000 100,000 150,000 200,000 250,000 300,000 350,000
“But we are interested in future harm, not
past harm”
• We need to embrace the challenges and opportunities set out by the Health Foundation’s The measurement and monitoring of patient safety
• But past harm matters because: – The NHS today is not so very different from the NHS earlier
this year; our processes, pressures, patient groups, staff, buildings, equipment, and training will not have radically changed since the period these data are drawn from
– Therefore the patterns of human error, and poorly designed systems that fail to prevent harm reaching the patient, are likely to recur until we make improvements
Don’t count incident reports, read them….
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
Vulnerable groups
Vulnerable points of
care
Key types of harm
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
In
teg
rate
d P
ati
en
t
Safe
ty S
tra
teg
y f
or
the N
HS
www.england.nhs.uk
National Patient Safety Alerting
System (NaPSAS)
www.england.nhs.uk
• A new system launched in January
2014 for alerting the NHS to
emerging patient safety risks
• Builds on the best elements of the
former National Patient Safety
Agency (NPSA) system
• A three-stage alerting system
based on other high risk industries
such as aviation
NRLS death & severe
Potential new risks received from:
Coroners
NHS staff
Professional bodies
Clinical audit/mortality
Public/patients
Other national organisations
NO ACTION- risk not significant- action already underway- action not feasible
Resolution:
FOR ACTION BY OTHERSInformation handed over
NaPSAS ALERT1. Warning2. Resource3. Directive
FOR OTHER ACTIONe.g. social movements,
collaboratives, education, etc.
Triage:
Discussion
Information gathering
Detailed insight from expert groups
Decision
Targeted audience ‘Story’ of trigger
incident
Number and nature of similar
errors
Works with differing levels of organisational maturity
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
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
Vulnerable groups
Vulnerable points of
care
Key types of harm
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
In
teg
rate
d P
ati
en
t
Safe
ty S
tra
teg
y f
or
the N
HS
www.england.nhs.uk
Scale of the problem: death & severe harm
19%
17%
14%8%
6%
6%
6%
5%
9% Suicide/severe self harm
Fall (hip #/sub-dural)
Pressure ulcer grade 4
Treatment error or delay
Obstetric-specific incident
Operation/procedure related
Clinical diagnostic error/delay
Missed deterioration
Medication incident
Healthcare associated infection
Pulmonary embolus
Test results not acted on
Transfer or discharge incident
Other/unclear
NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data: 8,018 incidents
Over 8,000 reported fatal or severe harm incidents each year
Scale of the problem: other sources
• Around 4,400 people commit suicide each year; 27% are known to mental health services; most are known to GPs
• 4,849 deaths related to VTE within 120 days of hospital admission (for reasons other than VTE) each year
• 9,500 patients with grade 2/3/4 pressure ulcers on each monthly survey
• Around 3,000 hip fractures from falls in hospitals each year identified by the National Hip Fracture database
NCISH 2014 report - HSCIC NHS OF Aug 2014 - Safety Thermometer Sept 2014 – NHFD 2014 report
Suicides - England 2002-2012
The largest areas of harm remain large because they are ‘wicked problems’ which need complex, wide-ranging and sustained improvement efforts
2007
20142020
2015
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
Vulnerable groups
Vulnerable points of
care
Key types of harm
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
In
teg
rate
d P
ati
en
t
Safe
ty S
tra
teg
y f
or
the N
HS
www.england.nhs.uk
17
• 5% of deaths potentially avoidable Median age 80 years
Main problem types:• Clinical
monitoring (in the broad sense) 31%
• Diagnostic error & delay 30%
• Fluids and medication 21%
• Average 4 problems in healthcare per avoidable death
Patient Safety
Incident
Not classic Swiss cheese “bull’s eye”
Patient
Cumulative effect of more minor harms“death by a thousand cuts”
Are you confident potentially avoidable deaths discussed in mortality meetings are reported as incidents and known to your Board?
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
Vulnerable groups
Vulnerable points of
care
Key types of harm
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
In
teg
rate
d P
ati
en
t
Safe
ty S
tra
teg
y f
or
the N
HS
www.england.nhs.uk
Acute care settings: patient age within death and severe harm incidents
22
21%
27%
17%
9%
6%
7%
6%
3%4%
Over 85 years
76 to 85 years
66 to 75 years
56 to 65 years
46 to 55 years
36 to 45 years
26 to 35 years
18 to 25 years
Under 17 years
NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
Vulnerable groups
Vulnerable points of
care
Key types of harm
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
In
teg
rate
d P
ati
en
t
Safe
ty S
tra
teg
y f
or
the N
HS
www.england.nhs.uk
25
26
And the response to NHS Choices publication?
29
http://blogs.bmj.com/bmj/2014/05/09/tara-lamont-on-failing-well-
archie-cochranes-legacy/
@TaraJLamont
Archie Cochrane
30www.england.nhs.uk
31www.england.nhs.uk
“The results at that stage showed a slight numerical
advantage for those who had been treated at home. It was of
course completely insignificant statistically.
“I rather wickedly compiled two reports, one reversing the
numbers of deaths on the two sides of the trial. As we were
going into committee, in the anteroom, I showed some
cardiologists the results……..
32
“……they were vociferous in their abuse: `Archie’, they said,
`we always thought you were unethical. You must stop the
trial at once…’
“I let them have their say for some time and then apologised
and gave them the true results, challenging them to say, as
vehemently, that coronary care units should be stopped
immediately.
“There was dead silence and I felt rather sick because they
were, after all, my medical colleagues.”
Professor Archibald Cochrane & Max Blythe One Man's Medicine (1989) p.211
33
“cognitive dissonance”
http://britishgeriatricssociety.wordpress.com/2013/05/16/all-down-to-numbers/
“data used for reassurance”
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
Vulnerable groups
Vulnerable points of
care
Key types of harm
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
In
teg
rate
d P
ati
en
t
Safe
ty S
tra
teg
y f
or
the N
HS
www.england.nhs.uk
http://m.qualitysafety.bmj.com/content/23/11/880.full
"The consistent delivery of well-executed safe care under typically difficult circumstances tends to go unrecognised"
