# Patient safety: thinking differently Exploring the challenges in patient safety improvement from national, local and personal perspectives Frances Healey,

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• 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 England1 April 2015

• Chart1

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48230.01

107200.04

265080.13

623510.25

880420.3

1271700.39

1403940.46

1611410.49

1665390.5

1927940.54

1795380.62

2101780.63

2240470.66

2053570.64

2510100.68

2132810.64

2530060.62

2348630.67

2671350.73

2558360.74

3021980.83

2804540.81

3227570.89

2849620.87

3138260.9

2860960.85

3371480.89

3129800.87

3353450.8

3234460.77

354088Oct - Dec 2011

Incidents submitted

Average proportion of trusts reporting per month

NRLS Quarterly data workbook: Incidents occurring between 1 October 2010 - 30 September 2011

PLEASE TAKE INTO ACCOUNT THE FOLLOWING WHEN USING THE DATA

1. All data presented in Section 1 (S.1) were derived using the date the incident was submitted to the NRLS.

2. All data presented in Section 2 (S.2) were derived using the date that the incident is reported to have occurred

3. Data include all reports made from NHS organisations in England and Wales to the NRLS

4. The 'Total' figures may exceed the combined figures for England and Wales, as a small number of incidents have missing values for location.

The following notation is used in the tables:

0 is used for percentages that are rounded down to zero;

- is used for a true zero in columns showing percent, i.e. when there are no cases in a category;

* is used when the base number is deemed too small to provide reliable percentages (n

• NHS Englands Integrated Patient Safety Strategy for the NHSwww.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

Chart1

1580

17160.01

48230.01

107200.04

265080.13

623510.25

880420.3

1271700.39

1403940.46

1611410.49

1665390.5

1927940.54

1795380.62

2101780.63

2240470.66

2053570.64

2510100.68

2132810.64

2530060.62

2348630.67

2671350.73

2558360.74

3021980.83

2804540.81

3227570.89

2849620.87

3138260.9

2860960.85

3371480.89

3129800.87

3353450.8

3234460.77

354088Oct - Dec 2011

Incidents submitted

Average proportion of trusts reporting per month

NRLS Quarterly data workbook: Incidents occurring between 1 October 2010 - 30 September 2011

PLEASE TAKE INTO ACCOUNT THE FOLLOWING WHEN USING THE DATA

1. All data presented in Section 1 (S.1) were derived using the date the incident was submitted to the NRLS.

2. All data presented in Section 2 (S.2) were derived using the date that the incident is reported to have occurred

3. Data include all reports made from NHS organisations in England and Wales to the NRLS

4. The 'Total' figures may exceed the combined figures for England and Wales, as a small number of incidents have missing values for location.

The following notation is used in the tables:

0 is used for percentages that are rounded down to zero;

- is used for a true zero in columns showing percent, i.e. when there are no cases in a category;

* is used when the base number is deemed too small to provide reliable percentages (n

• 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

• But we are interested in future harm, not past harm We need to embrace the challenges and opportunities set out by the Health Foundations The measurement and monitoring of patient safetyBut 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

• Dont count incident reports, read them.

• NHS Englands Integrated Patient Safety Strategy for the NHSwww.england.nhs.uk

• National Patient Safety Alerting System (NaPSAS)www.england.nhs.ukA 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: CoronersNHS staffProfessional bodiesClinical audit/mortalityPublic/patientsOther national organisationsNO ACTION- risk not significant- action already underway- action not feasible Resolution: FOR ACTION BY OTHERSInformation handed over NaPSAS ALERTWarningResourceDirective FOR OTHER ACTIONe.g. social movements, collaboratives, education, etc.Triage: Discussion

Information gathering

Detailed insight from expert groups

Decision

• Targeted audience Story of trigger incidentNumber and nature of similar errors

• Works with differing levels of organisational maturityA. Why waste our time on safety?B. We do something when we have an incidentC. We have systems in place to manage all identified risksD. We are always on the alert for risks that might emergeE. Risk management is an integral part of everything that we doPATHOLOGICALREACTIVEBUREAUCRATICPROACTIVEGENERATIVEThe Manchester Patient Safety Assessment Framework

• NHS Englands Integrated Patient Safety Strategy for the NHSwww.england.nhs.uk

• Scale of the problem: death & severe harm NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data: 8,018 incidentsOver 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 GPs4,849 deaths related to VTE within 120 days of hospital admission (for reasons other than VTE) each year9,500 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 2002-2012The largest areas of harm remain large because they are wicked problems which need complex, wide-ranging and sustained improvement efforts:

• 2007201420202015

• NHS Englands Integrated Patient Safety Strategy for the NHSwww.england.nhs.uk

• *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 IncidentNot classic Swiss cheese bulls eye

• PatientCumulative effect of more minor harmsdeath by a thousand cuts

• Problems in healthcareFemale patient in her 80s with a past history of stroke was admitted with a chest infection. An early CT scan showed a dilated oesophagus with food residue. She was kept nil by mouth for 5 days waiting for a swallowing assessment (problem 1/diagnosis and assessment). Fluid balance during that period was poorly charted (problem 2/clinical monitoring) but laboratory tests indicated developing dehydration. No changes in fluid regime were made in response (problem 3/drugs and fluids). On day 5 a trip over the drip stand (problem 4/other) led to a fractured femur. The patient died from post -operative renal failure, to which her poor preoperative state had contributed.

Are you confident potentially avoidable deaths discussed in mortality meetings are reported as incidents and known to your Board?

• NHS Englands Integrated Patient Safety Strategy for the NHSwww.england.nhs.uk

• Acute care settings: patient age within death and severe harm incidents *NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data

• NHS Englands Integrated Patient Safety Strategy for the NHSwww.england.nhs.uk

• *Recap: types of ward level indicator Hierarchy of activities not done Therefore measuring a few processes that are easier to measure gives a good indication of what other activities will also have been delivered /not delivered

• And the response to NHS Choices publication?

• *This [MH unit for older people] has no physio input. Balance and strength assessments never get doneRoyal College of Physicians 2012 Report of the 2011 inpatient falls pilot audit www.rcplondon.ac.uk Are we ready to measure frontline care?

• NHS Englands Integrated Patient Safety Strategy for the NHSwww.england.nhs.uk

• http://blogs.bmj.com/bmj/2014/05/09/tara-lamont-on-failing-well-archie-cochranes-legacy/

@TaraJLamont Archie Cochrane *www.england.nhs.uk

• *www.england.nhs.ukThe results at that stage

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