Safer Systems for Safer Healthcare

Dr. Maureen Baker CBE DM FRCGPClinical Director for Patient Safety

NHS Connecting for Health

Overview

• The NHS• The NPfIT• Development of patient safety movement• Safety management systems• NHS CFH Clinical Safety Management System• Experience so far• Next steps

The UK National Health Service

• UK population 60 Million• Almost 1 Million consultations with GPs every

working day• 100,000 people in hospital every working day• NHS covers every health sector• 4 country model• 750 Million prescription items from general

practice in England per annum

The National Programme for IT in the NHS in England

• Established 2002• Has a number of central features and programmes

(National Spine; Choose and Book; GP2GP; National Care Record Service; Picture Archive and Communications Service; Electronic Transfer of Prescriptions)

• Local Service Providers• Estimated cost US$25 Billion over 10 years (contracts,

training and implementation)• Being delivered by NHS Connecting for Health

Some definitions

Patient Safety – freedom from accidental harm to individuals receiving healthcare

Patient Safety Incident – an episode when something goes wrong in healthcare resulting in potential or actual harm to patients

NPSA Report on Safety in NPfIT

• National Patient Safety Agency established 2001

• Report commissioned 2004• Conducted by NPSA Risk Advisor

Report Findings

• Not identifying safety as a benefit to drive the programme

• No formal risk assessment• No formal safety management system• Reliance on clinicians to instinctively address

patient safety problems

• NPfIT not addressing safety in structured, pro-active manner and other safety critical industries would

Safety Critical Industries with Safety Approach

Aviation

Railways

Oil and Gas

Construction

Nuclear

Military

NHS CFH Clinical Safety Management System

• Based on principles of IEC 61508• Light touch, yet robust• Three key pieces of documentation• Practical and pragmatic – in place for almost 4

years• Supplemented by established Safety Incident

Management Process

NHS CFH CSMS Deliverables

• Hazard assessment• Safety case• Safety closure report• Clinical Authority to Release (CATR) (Includes ‘caveats’)

Safety

Closure

Report

Patient

Safety

AssessmentClinical

Systems

Safety Case

Safety

Closure

Report

Safety

Closure

Report

Patient

Safety

Assessment

Patient

Safety

AssessmentClinical

Systems

Safety Case

Clinical

Systems

Safety Case

Safer Care, i.e.:• x > y = a+b

What we are trying to achieve?

Risk

Baker, M et al, Safer IT in a Safer NHS: Account of a Partnership, The British Healthcare Computing & Information Management, Vol. 23 No. 7 Sept 2006

Safety Incident Management System

• Incidents related to Health IT reported and logged

• Assessed and managed by Clinical Safety Group (clinicians and safety engineers)

• Aim to ‘make safe’ (remove potential for harm) with 24 hours

• Around 430 incidents reported since 2005• 97% made safe within 24 hours

NHS IT – What can go wrong?

• Patient identification (wrong notes, wrong results, wrong procedure)

• Data migration (re-start discontinued drugs, incorrect preservation of meaning)

• Data mapping (mapped to non-identical preparation, eg long-acting or slow release)

• Data corruption (over-writing of info on NHS Spine)

Safety Workstreams in NHS CFH

• Safe IT systems (as safe as design and forethought will allow)

• Safety Incident Management Process• Training for accreditation and safe

implementation• Technology for patient safety

Accredited Clinician Programme

• Dedicated training in principles of safety and risk as applied to Health IT

• In 4+ years trained over 550 delegates, approx 60% are clinicians

• Clinicians must be registered with appropriate regulatory body

• Supports clinical input to activity by appropriately trained and qualified clinicians

Passing the Safety Baton

NHS CFH (and Software Providers)

Support from:• Clinical Safety Group

Clinical Authority to Release

Implementing organisation (Hospitals Pharmacists, GPs etc.)

Support from:• Internal Risk Team

Safer Design and Development

Safer Implementation

Passing the Baton – Ownership passed from NHS CFH to NHS

Implementation Network

• Aimed at individuals in NHS Trusts with direct responsibility for significant IT implementations

• Develop a community of interest• Explicitly designed to facilitate networking and

peer support• Dedicated website • Buddying• Could be used in support of ‘User Standard’

Technology for Patient Safety

• Right Patient Right Care (tracking technologies – RFID; wristband datasets; NHS number)

• Safer prescribing (prompts + alerts, tallman)• Safer handover (core dataset)• Electronic risk assessment tool for VTE• Tracking of results• Deteriorating patients

Design and the NHS

“The NHS is seriously out of step with modern thinking and practice with regards to design …. And also fails to understand what design thinking can bring to an organisation …. A direct consequence of this has been a significant incidence of avoidable risk and error”

Department of Health & Design Council,

Design for Patient Safety Report

Building a House

Next steps

• Focus on design and human factors for inherently safe systems

• Support implementation of standards (NHS and international) for suppliers and users

• Passing the safety baton• Identification and safe implementation of

technology for safer care

National Programme for IT in NHS

“ The National Programme is not just an IT programme, but a patient safety and clinical governance programme”

Gordon Hextall, Chief Operating Officer

NHS Connecting for Health

Conclusion

• Healthcare is a safety critical industry• IT systems don’t deliver care, but are used by

clinicians in the delivery of care• Good safety practice requires proactive work –

systems as safe as design and forethought will allow

• Also reactive systems to detect and manage errors• All encompassed in CSMS and within emerging

Standards