Transcript NHS: High quality care for all – now and for future

A vision: using data to ensure
the safe provision of care
Dr Bruce Warner
Deputy Director of Patient
Safety
NHS England
International and National Recognition of
Patient Safety
1999
2
2000
2001
June 2012 – from the National Patient Safety
Agency to the NHS Commissioning Board
“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.”
2
Time to Move On
NPSA Patient Safety
Division
NRLS
to
ICHT
4
Patient Safety Function
to
NHSCB(A)
Patient safety as an essential
component of quality
““… [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
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Safety
Effectiveness
Patient
experience
Safety is not a minimum
threshold – all services
can and should strive to
excellence in safety
E. Risk
management is an
integral part of
everything that we
do
A. Why waste our
time on safety?
PATHOLOGICAL
B. We do
something when
we have an
incident
REACTIVE
C. We have
systems in place
to manage all
identified risks
D. We are always
on the alert for
risks that might
emerge
BUREAUCRATIC PROACTIVE
The Manchester Patient Safety Assessment Framework
GENERATIVE
NHS Outcomes framework
8
The interplay between patient safety and
clinical guidelines
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.
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Understanding the National
Reporting and Learning
System
The National Reporting and Learning System
(NRLS)
www
NHS net
The system collects
Local Risk
Management
System
1
1
•
•
•
•
all types of incidents
from all care settings
from all specialties
from all staff groups
Open
Access
E-Forms
National Reporting & Learning
System
NHS Trusts
International
NRLS
Practitioners
& Staff
Community
Pharmacy
multiples
Patients
Carers
Standardised reporting
Commissioners
Collaboration
Australia
USA
CQC
MHRA
NHS Complaints
NHS Litigation
Authority
Europe
NRLS definitions
NO HARM
PATIENT SAFETY
INCIDENT
Any unintended or
unexpected incident(s)
which could have or
did lead to harm for
one or more persons
receiving NHS
funded care
Prevented,
not impacted on
patient
LOW
MODERATE
SEVERE
DEATH
Not prevented,
but resulted in
no harm
By 31 March 2012
7,070,261
reports had been
reported.
Approximately
3,700 incidents
are reported to the
NRLS per day.
94%
Around
of
incidents cause low
or no harm
1
4
NRLS limitations:
very little reporting from general practice
1
5
Chart 1: Proportion of incidents by care setting for incidents reported to the NRLS 2010/11
Patient safety incidents reported to
the NRLS
Chart 2: Proportion of incidents by incident type and quarter, Oct 2010 - Sep 2011
Patient accident
Medication
Treatment, procedure
Implementation of care and ongoing monitoring / review
Access, admission, transfer, discharge (including missing patient)
Documentation (including records, identification)
Oct 2010 - Dec 2010
Infrastructure (including staffing, facilities, environment)
Jan 2011 - Mar 2011
Clinical assessment (including diagnosis, scans, tests,…
Other
Apr 2011 - Jun 2011
Disruptive, aggressive behaviour
Jul 2011 - Sep 2011
Self-harming behaviour
Consent, communication, confidentiality
Medical device / equipment
Infection Control Incident
Patient abuse (by staff / third party)
0
1
6
5
10
15
Percent
20
25
30
2%
3%
1%
1%
1%
Pressure ulcer grade 4 or above
1%
Fall
Suicide/severe self harm
19%
4%
Treatment error or delay (excluding medication
Other or unable to theme
5%
Obstetric-specific incident
5%
Operation/ procedure
Clinical diagnostic error including delay of diagnosis
6%
Deterioration not recognised or not acted on
17%
Healthcare associated infection
Medication incident
6%
Test results not seen or not acted on (any type of test)
Transfer or discharge incident
8%
12%
9%
Pulmonary embolus - hospital acquired
Resuscitation (excluding medication)
Airway obstruction/ Aspiration pneumonia
All care settings: death and severe harm themes 2011/12
1
7
Searching by keywords: example
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
1
8
We need a trigger
Different solutions for
different problems
Education and training will not prevent
slips and lapse or violations and we will
constantly have new junior staff with
knowledge gaps
Violations
Routine
Reasoned
Reckless
Malicious
Intended
actions
Unsafe
acts
Unintended
actions
Mistakes
Rule & Knowledge
Based errors
Slips &
Lapses
Skill based errors
Memory or
attention failures
Routine violations: campaigns to
change culture and attitudes
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2
Slips and lapses: make the right thing
the easiest thing to do
2
3
Knowledge and rule based error: build
in senior advice and empower patients
2
4
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
2
NHS
| Presentation to [XXXX Company] | [Type Date]
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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
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Last words
The power is in the qualitative data
• “…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”
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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
Thank you for listening
[email protected]