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 England
1 April 2015
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
to save 6000 lives
Enha
ncin
g N
HS
capa
bilit
y an
d ca
paci
ty
to im
prov
e sa
fety
Gaining a better understanding of
what goes wrong in healthcare
Tackling key patient
safety priorities
Vulnerable groups
Vulnerable points of
care
Key types of harm
Syste
m wide c
ampaig
n
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
Inte
gra
ted
Pat
ien
t S
afet
y S
trat
egy
for
the
NH
S
www.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
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 Foundation’s The measurement and monitoring of patient safety
• But 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
Don’t count incident reports, read them….Don’t count incident reports, read them….
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
to save 6000 lives
Enha
ncin
g N
HS
capa
bilit
y an
d ca
paci
ty
to im
prov
e sa
fety
Gaining a better understanding of
what goes wrong in healthcare
Tackling key patient
safety priorities
Vulnerable groups
Vulnerable points of
care
Key types of harm
Syste
m wide c
ampaig
n
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
Inte
gra
ted
Pat
ien
t S
afet
y S
trat
egy
for
the
NH
S
www.england.nhs.uk
National Patient Safety Alerting System (NaPSAS)
www.england.nhs.uk
• A 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:
Coroners
NHS staff
Professional bodies
Clinical audit/mortality
Public/patients
Other national organisations
NO ACTION- risk not significant- action already underway- action not feasible
Resolution:
FOR ACTION BY OTHERSInformation handed over
NaPSAS ALERT1.Warning2.Resource3.Directive
FOR OTHER ACTIONe.g. social movements,
collaboratives, education, etc.
Triage:
Discussion
Information gathering
Detailed insight from expert groups
Decision
Targeted audience Targeted audience ‘Story’ of trigger
incident‘Story’ of trigger
incident
Number and nature of similar
errors
Number and nature of similar
errors
Works with differing levels of organisational maturity
A. Why waste our time on
safety?
B. We do something when we have an incident
C. We have systems in
place to manage all identified
risks
D. We are always on
the alert for risks that
might emerge
E. Risk management is an integral
part of everything that we do
PATHOLOGICAL REACTIVE BUREAUCRATIC PROACTIVE GENERATIVE
The Manchester Patient Safety Assessment Framework
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
to save 6000 lives
Enha
ncin
g N
HS
capa
bilit
y an
d ca
paci
ty
to im
prov
e sa
fety
Gaining a better understanding of
what goes wrong in healthcare
Tackling key patient
safety priorities
Vulnerable groups
Vulnerable points of
care
Key types of harm
Syste
m wide c
ampaig
n
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
Inte
gra
ted
Pat
ien
t S
afet
y S
trat
egy
for
the
NH
S
www.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 incidents
Over 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 GPs
• 4,849 deaths related to VTE within 120 days of hospital admission (for reasons other than VTE) each year
• 9,500 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 2002-2012
The largest areas of harm remain large because they are ‘wicked problems’ which need complex, wide-ranging and sustained improvement efforts:
2007
20142020
2015
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
to save 6000 lives
Enha
ncin
g N
HS
capa
bilit
y an
d ca
paci
ty
to im
prov
e sa
fety
Gaining a better understanding of
what goes wrong in healthcare
Tackling key patient
safety priorities
Vulnerable groups
Vulnerable points of
care
Key types of harm
Syste
m wide c
ampaig
n
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
Inte
gra
ted
Pat
ien
t S
afet
y S
trat
egy
for
the
NH
S
www.england.nhs.uk
18
• 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 Incident
Not classic Swiss cheese “bull’s eye”
Patient
Cumulative effect of more minor harms“death by a thousand cuts”
Problems in healthcare• Female 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?
Are you confident potentially avoidable deaths discussed in mortality meetings are reported as incidents and known to your Board?
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
to save 6000 lives
Enha
ncin
g N
HS
capa
bilit
y an
d ca
paci
ty
to im
prov
e sa
fety
Gaining a better understanding of
what goes wrong in healthcare
Tackling key patient
safety priorities
Vulnerable groups
Vulnerable points of
care
Key types of harm
Syste
m wide c
ampaig
n
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
Inte
gra
ted
Pat
ien
t S
afet
y S
trat
egy
for
the
NH
S
www.england.nhs.uk
Acute care settings: patient age within death and severe harm incidents
23NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
to save 6000 lives
Enha
ncin
g N
HS
capa
bilit
y an
d ca
paci
ty
to im
prov
e sa
fety
Gaining a better understanding of
what goes wrong in healthcare
Tackling key patient
safety priorities
Vulnerable groups
Vulnerable points of
care
Key types of harm
Syste
m wide c
ampaig
n
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
Inte
gra
ted
Pat
ien
t S
afet
y S
trat
egy
for
the
NH
S
www.england.nhs.uk
27
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? And the response to NHS Choices publication?
29
“This [MH unit for older people] has no physio input. Balance and strength assessments never get done”
Royal College of Physicians 2012 Report of the 2011 inpatient falls pilot audit www.rcplondon.ac.uk
Are we ready to measure frontline care?
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
to save 6000 lives
Enha
ncin
g N
HS
capa
bilit
y an
d ca
paci
ty
to im
prov
e sa
fety
Gaining a better understanding of
what goes wrong in healthcare
Tackling key patient
safety priorities
Vulnerable groups
Vulnerable points of
care
Key types of harm
Syste
m wide c
ampaig
n
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
Inte
gra
ted
Pat
ien
t S
afet
y S
trat
egy
for
the
NH
S
www.england.nhs.uk
http://blogs.bmj.com/bmj/2014/05/09/tara-lamont-on-failing-well-archie-cochranes-legacy/
@TaraJLamont
Archie Cochrane
31www.england.nhs.uk
32www.england.nhs.uk
“The 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……..
33
“……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
34
“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 culture”
Were 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 failure
Guidance on appropriate
management action, centred on disciplinary
sanctions
The NPSA Incident Decision Tree
YES
Is there evidence of physical or mental ill-health?
Based on James Reason’s culpability model
Patient Safety
’Fellows’
Patient Safety Collaboratives
A system devoted to continual
learning and improvement
NRLS
NaPSAS
Data
Transparency
Retrospective case note
review
to save 6000 lives
Enha
ncin
g N
HS
capa
bilit
y an
d ca
paci
ty
to im
prov
e sa
fety
Gaining a better understanding of
what goes wrong in healthcare
Tackling key patient
safety priorities
Vulnerable groups
Vulnerable points of
care
Key types of harm
Syste
m wide c
ampaig
n
and reduce harm by 50%
SAFE team
NH
S E
ng
lan
d’s
Inte
gra
ted
Pat
ien
t S
afet
y S
trat
egy
for
the
NH
S
www.england.nhs.uk
http://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"
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