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 2015Chart1158017160.0148230.01107200.04265080.13623510.25880420.31271700.391403940.461611410.491665390.51927940.541795380.622101780.632240470.662053570.642510100.682132810.642530060.622348630.672671350.732558360.743021980.832804540.813227570.892849620.873138260.92860960.853371480.893129800.873353450.83234460.77354088Oct - Dec 2011Incidents submittedAverage proportion of trusts reporting per monthIMPORTANT - PLEASE READNRLS Quarterly data workbook: Incidents occurring between 1 October 2010 - 30 September 2011PLEASE TAKE INTO ACCOUNT THE FOLLOWING WHEN USING THE DATA1. 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 occurred3. Data include all reports made from NHS organisations in England and Wales to the NRLS4. 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 (nNHS Englands Integrated Patient Safety Strategy for the NHSwww.england.nhs.ukAround 12,000,000 incidents have been reported.Approximately 4,000 incidents are reported to the NRLS per dayAround 94% of incidents cause low or no harm Chart1158017160.0148230.01107200.04265080.13623510.25880420.31271700.391403940.461611410.491665390.51927940.541795380.622101780.632240470.662053570.642510100.682132810.642530060.622348630.672671350.732558360.743021980.832804540.813227570.892849620.873138260.92860960.853371480.893129800.873353450.83234460.77354088Oct - Dec 2011Incidents submittedAverage proportion of trusts reporting per monthIMPORTANT - PLEASE READNRLS Quarterly data workbook: Incidents occurring between 1 October 2010 - 30 September 2011PLEASE TAKE INTO ACCOUNT THE FOLLOWING WHEN USING THE DATA1. 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 occurred3. Data include all reports made from NHS organisations in England and Wales to the NRLS4. 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 (nScale 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.ukNational Patient Safety Alerting System (NaPSAS)www.england.nhs.ukA new system launched in January 2014 for alerting the NHS to emerging patient safety risksBuilds on the best elements of the former National Patient Safety Agency (NPSA) systemA three-stage alerting system based on other high risk industries such as aviationNRLS 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: DiscussionInformation gatheringDetailed insight from expert groups DecisionTargeted 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.ukScale 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: 2007201420202015NHS Englands Integrated Patient Safety Strategy for the NHSwww.england.nhs.uk*5% of deaths potentially avoidable Median age 80 yearsMain problem types:Clinical monitoring (in the broad sense) 31%Diagnostic error & delay 30%Fluids and medication 21% Average 4 problems in healthcare per avoidable deathPatient 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.ukAcute care settings: patient age within death and severe harm incidents *NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England dataNHS 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.ukhttp://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 showed a slight numerical advantage for those who had been treated at home. It was of course completely insignificant statistically. I rather wickedly compiled two reports, one reversing the numbers of deaths on the two sides of the trial. As we were going into committee, in the anteroom, I showed some cardiologists the results..*they were vociferous in their abuse: `Archie, they said, `we always thought you were unethical. You must stop the trial at once I let them have their say for some time and then apologised and gave them the true results, challenging them to say, as vehemently, that coronary care units should be stopped immediately. There was dead silence and I felt rather sick because they were, after all, my medical colleagues.Professor Archibald Cochrane & Max Blythe One Man's Medicine (1989) p.211*cognitive dissonance http://britishgeriatricssociety.wordpress.com/2013/05/16/all-down-to-numbers/ data used for reassurance HSJ November 2011 (response to first SHMI publication) Dr X, Medical Director at Trust A blamed his organisation's rating on the inclusion of data from a hospice which is not run by the Trust. Trust B said that the new indicator does not take into account levels of deprivation which has put it at a disadvantage. However Trust C said it was taking the rating "extremely seriously" and has commissioned an external review. There is no such thing as patient safety cultureWere the adverse consequences intended?Guidance on appropriate management action, centred on support to become fit to work safely again Guidance on appropriate management action, centred on criminal sanctions Guidance on appropriate management action, may be training/insight/supervision needs No management action to be directed at staff involved - systems failureGuidance on appropriate management action, centred on disciplinary sanctions The NPSA Incident Decision Tree YESIs there evidence of physical or mental ill-health? Based on James Reasons culpability modelNHS Englands Integrated Patient Safety Strategy for the NHSwww.england.nhs.ukhttp://m.qualitysafety.bmj.com/content/23/11/880.full"The consistent delivery of well-executed safe care under typically difficult circumstances tends to go unrecognised" Thank you! frances.healey@nhs.net@FrancesHealey **MaPSaF Medway 23 May 2011**So back to falls. This is the timeline of our main initiatives and resources from the past five years they are listed in the abstract and Ill come back to each in more detail later, with the exception of the batch of bedrail and restraint resources that Im speaking about this afternoon. ******So that pretty much covers what in the UK we believe we ought to be doing in hospital falls prevention and this afternoon Ill be talking more about the challenges of actually doing it, especially in patients with dementia or delirium. *

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