Transcript Safer Systems for a Safer NHS Dr. Maureen Baker CBE DM FRCGP Clinical Director for Patient Safety NHS Connecting for Health Overview • • • • • The NHS The National.

Safer Systems for a Safer NHS
Dr. Maureen Baker CBE DM FRCGP
Clinical Director for Patient Safety
NHS Connecting for Health
Overview
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The NHS
The National Programme for IT (NPfIT)
Development of patient safety movement
Safety management systems
NHS Connecting for Health (NHS CFH) Clinical Safety
Management System
• Experience so far
• Next steps
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 Prescription
Service)
• Local Service Providers
• Estimated cost £12.4 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 (NPSA)
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, proactive 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
[CSMS]
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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
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Hazard assessment
Safety case
Safety closure report
Clinical Authority to Release (CATR)
(Includes ‘caveats’)
Patient
Safety
Assessment
Safety
Clinical
Systems
Safety Case
Closure
Report
What we are trying to achieve?
Safer Care, i.e.:
• x > y = a+b
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
• 442 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, e.g. 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
• Since 2005 over 680 delegates have been
trained, 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)
Safer Design
and Development
Support from:
• Clinical Safety Group
Implementing organisation
(Hospitals Pharmacists, GPs etc.)
Safer Implementation
Support from:
• Internal Risk Team
Clinical Authority to Release
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 – Radio Frequency Identification
(RFID); wristband datasets; NHS number)
• Safer prescribing (prompts + alerts, tallman)
• Safer handover (core dataset)
• Electronic risk assessment tool for Venous
Thromboembolism (VTE)
• Tracking of results
• Deteriorating patients
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
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