A vision: using data to ensure the safe provision of care

Dr Bruce WarnerDeputy Director of Patient

SafetyNHS England

International and National Recognition of Patient Safety

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1999 2000 2001

June 2012 – from the National Patient Safety Agency to the NHS Commissioning Board

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“We propose to abolish the National Patient Safety Agency”

“The work of the Patient Safety Division relating to reporting and learning from serious patient safety incidents should move to the NHS Commissioning Board…

… covering the whole function from getting evidence to working up evidence-based safe services.”

Time to Move On

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Patient safety as an essential component of quality

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““… [we all] need to place the safety of patients at the forefront of the agenda in healthcare. Safety cannot be allowed to play second fiddle to other objectives that may emerge from time to time. It is the first objective.”Sir Ian Kennedy, Chairman Healthcare Commission

Patient experience

Safety

Effectiveness

Safety is not a minimum threshold – all services can and should strive to excellence in safety

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

NHS Outcomes framework

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The interplay between patient safety and clinical guidelines

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It is about the way we safely deliver care once the

clinical decision on how to treat has been made –

the clinical decision may be the right one but it is not

a given that we will deliver it without error.

NHS | Presentation to [XXXX Company] | [Type Date]10

Understanding the National Reporting and Learning System

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The National Reporting and Learning System (NRLS)

Local Risk ManagementSystem

Open AccessE-Forms

NHS netwww

The system collects

•all types of incidents•from all care settings•from all specialties•from all staff groups

National Reporting & Learning System

NHS Trusts

Practitioners & Staff

Patients

Carers

NRLS

CQC

MHRA

NHS Complaints

NHS Litigation Authority

International

Collaboration

Australia

USA

Europe

Sta

nd

ard

ised

rep

ortin

gCommunity Pharmacy multiples

Commissioners

PATIENT SAFETYINCIDENTAny unintended orunexpected incident(s)which could have ordid lead to harm forone or more personsreceiving NHSfunded care

NO HARM

LOW

MODERATE

SEVERE

DEATH

Not prevented,but resulted inno harm

Prevented, not impacted onpatient

NRLS definitions

Good Catch

Good Luck!

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By 31 March 2012

7,070,261 reports had been reported.

Approximately

3,700 incidents are reported to the NRLS per day.

Around 94% of incidents cause low or no harm

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Chart 1: Proportion of incidents by care setting for incidents reported to the NRLS 2010/11

NRLS limitations:very little reporting from general practice

Patient safety incidents reported to the NRLS

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All care settings: death and severe harm themes 2011/1217

Searching by keywords: example

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NICE Quality Standard for Bacterial meningitis and meningococcal septicaemia in children

Key word search for ‘mening*’ in free text of incident reports identified 182 relevant incidents, all clinically reviewed and themes summarised to inform the development of the Quality Standard

We need a trigger

NHS | Presentation to [XXXX Company] | [Type Date]20

Different solutions for different problems

Unsafeacts

Unintendedactions

Intendedactions

Skill based errorsMemory or

attention failures

Rule & Knowledge Based errors

RoutineReasonedReckless Malicious

Violations

Mistakes

Slips & Lapses

Education and training will not prevent slips and lapse or violations and we will constantly have new junior staff with knowledge gaps

Routine violations: campaigns to change culture and attitudes

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Slips and lapses: make the right thing the easiest thing to do

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Knowledge and rule based error: build in senior advice and empower patients

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Patient Safety Reports for NICE QS

Local audit data

PCT audit of vaccine storage in

GP practices shared with NPSA

Significant proportion of vaccines

stored outside recommended

temperature range

NRLS Searched

National guidance produced

NHS | Presentation to [XXXX Company] | [Type Date]26

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Rapid but robust process:• NRLS search• Threshold criteria• Literature search• Topic expert advice• Patient and carer perspective • Formal consultation (100+) • ‘Still safe and relevant?’ reviews

NHS | Presentation to [XXXX Company] | [Type Date]28

Last words

The power is in the qualitative data

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• “…called to A wing…prisoner in cardiac arrest….had attended healthcare unit yesterday complaining of indigestion, given Gaviscon, no access to previous health records (recent transfer), in hindsight probably missed diagnosis of acute coronary syndrome…….”

• “Terminally ill patient required switch to syringe driver as no longer able to take oral meds; only one community nurse on duty this Sunday for [large geographical area] and 17 urgent visits already on list; five hour delay causing much distress to patient and family”

Sepsis Report

• Whole report based on 10 case studies

• Power was not in the 37,000 deaths a year but in the human storey

Jill’s Storey

Wrong Patient

Thank you for listening

bruce.warner@nhs.net