Transcript Slide 1

The Context
• Some facts and figures
• The interventions • The World Alliance for Patient Safety
• The Patients for Patient Safety initiative
Severity of incidents by care setting,
April 2006 to March 2007
Some facts and figures
Number of patient safety incidents reported, by quarter,
10/2003 to 9/2007
Reported incidents by type, July 2006
to June 2007
Care setting of incident reports
July 2006 to June 2007
Reported degree of harm to patients,
July 2006 to June 2007
The intervention - Working in
Partnership with Patients
Patients For Patient Safety
Part of the WHO Alliance for Patient
Safety
Who are we?
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Susan Sheridan*
• Co-founder Consumers Advancing Patient Safety, USA (Chair)
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Peter Mansell*
• Director for Patient Experience and Public Involvement, National Patient
Safety Agency, England and Wales
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Martin J. Hatlie
• President, Partnership for Patient Safety, USA
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Garance Upham*
• People's Health Movement, Disability and Economics Circle
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Jo Harkness
• Policy & External Affairs Director. International Alliance of Patients'
Organizations
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Helen Hughes
• World Health Organisation (Secretariat)
* = people who have experienced harm
The aim
To generate:
• a patient centred approach in patient safety
in health
• consumer interest and networks in patient
safety in/with
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the Alliance’s work strands
each other
and apply a method of identifying patient
safety champions
The Group’s role
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Defined in the statement of case
1. to help clinicians get the
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whole picture (we are often the only people who
see this)
and understand issues from a patient’s
perspectives such as social and economic
aspects
2. PFPS participating as equals; not victims.
3. We expect the spirit to be willing from
professionals but default behaviours to mean
we have to speak up!
Current work
• About 200 activists from around the world working
• Consumer champions’ workshops in WHO regions and
within countries
• WHO regional offices developing patient safety strategies
• Solutions products
• Research
• developing tools to measure harm
• working with teams delivering studies
• The global patient safety challenge
• pilot sites
• guidelines content
The patient involvement landscape and
experience within England
Reference points
• When things go wrong, [patients] and their families
suffer from the harm caused. Such harm is often
made worse by the defensive and secretive way
that many healthcare organisations respond in the
aftermath of a serious event.
• Partnership must be a key theme: patients, health
professionals, policymakers and healthcare leaders
should be working together to prevent avoidable
harm in healthcare. A particular focus is to challenge
the current culture of denial.
(Safety First 2006)
Where can patients add value?
• Sharing their insights
• Offering different perspectives
• Using experience for improvement
Sharing insights - Anticoagulants
Process steps
Patient experience and barriers to safe use
Decision to treat
Use of medical jargon and abbreviations unhelpful. Lay knowledge of warfarin is as “rat
killer” and this use needs to be described in context of patient anticoagulation for some.
Document and
Communicate
diagnosis and
treatment plan
Poor communication with carers. Stroke patients receive less information and support than
others. No planning for coping during first four weeks post-discharge, nor for longer term
regarding schooling, holidays, and other social events. Lack of information about effect of
foods and alcohol on anticoagulation control. Overall discharge is the weakest yet
critical stage.
Prescribe
Lack of communication between hospital consultant / clinic and GP when new drugs are
introduced – other prescribers can be unaware of this. Conflicting information about
aspirin; some are prescribed whilst others are told to avoid – the reasons for this need to be
explained. Conflicting advice is a source of anxiety – patients do talk to one another and
compare treatments.
Monitor
treatment
Home testing appreciated by patients but not by clinicians.
Offering different perspectives - number of
trusts that regularly report to the NRLS
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2,145,606 PSIs
Of the 427 NHS organisations in England and Wales,* 89%
October 2003 to December 2007 -
reported at least once between October to December
2007
• 57% of all NHS organisations didn’t report
at least once per month
Using experience for improvement - views on
medication – implications for commissioning
• Design
• Two people reported mistakes made in the use of
insulin pens, (slow-release and a quick-release),
which look identical. When one person was about
to go hypoglycaemic, they picked up the slowrelease pen by mistake and ended up in hospital.
“This is easy to do when you’re in a hurry and
anxious”.
Language, names and look of drugs
• Several participants described how a change in the
brand of a prescribed drug can create serious
problems, causing confusion and increasing the risk of
mistakes being made
• Implications for the NHS in commissioning:
• Spot market purchase brings its own set of risks
when viewed by patients
• Different look/Language/Names
So the impact of involving patients
can be to
• Provide new knowledge
• New ways of seeing things .. and so ..
• Provide a way to reconnect with people who
have lost trust
The NPSA contribution to you –
making space for staff and patients*
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May workshop linked to the Patient Safety Congress
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Three summit events aimed at answering:
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To foster and build collaboration and links between patients and staff on the
range of patient safety efforts at regional and local levels, so that lessons can
be shared and partnerships created.
What do safe health services look like?
What do safe GP services look like?
What do safe Mental health services look like?
Autumn workshop aimed at SHA alliances/federations and
patients to review work to date
Formational Workshops
Closing message
• Patient safety
• Can’t be achieved without the active
involvement of patients and those close to
them
• Is about trust and transparency as well as
reducing error and harm
• Our role is to help staff and patients regionally
and locally work together