Implementing Patient Safety Programmes – the story no one ever

wants to tell!

Expert Seminar - Paris

22 – 24 May 2006

Sue Osborn/Susan Williams

Joint Chief Executive

National Patient Safety Agency

“ to improve safety of patients by promoting a culture of reporting and learning from patient safety incidents affecting patients receiving National Health Service funded care”

Purpose of NPSA

Help the NHS to:• learn from things that go wrong• develop and implement solutions to problems• improve patient safety in frontline services

Focus on:• systems not individuals• learning not judgement• fairness not blame• openness not secrecy• all care settings not just acute

National Health Service

England

Scotland

Northern

Ireland

Wales

National Health Service

• State funded healthcare system• 3rd largest employer in the world behind Chinese

Army and Indian Rail Industry• Biggest organisation in Europe

UK context

• Population 65 million• 560 NHS Healthcare Organisations• 2 million prescriptions every day• 360 million patient contacts over a year• 40-50 million clinical decisions per million population per year• Budget £92.6 billion ($170.3 billion)• 7% of Gross Domestic Product (US 13.6%)

The National Patient Safety Agency

• Collect and analyse information on adverse events from local NHS organisations, NHS staff and patients and carers:

• Assimilate other safety-related information from a variety of existing reporting systems and other sources in this country and abroad;

• Learn lessons and ensure that they are fed back into practice, service organisations and delivery;

• Where risks are identified, produce solutions to prevent harm, specify national goals and establish mechanisms to track progress.

National Reporting & Learning System

• electronic system to enable NHS organisations,

staff and patients to report patient safety

incidents to a national database

• links to local risk management systems

• Source: Seven steps to patient safety: a guide for NHS Staff (NPSA)

‘any unintended or unexpected incident which could have or did lead to harm for one or more patient receiving NHS funded healthcare’

Patient safety incident

NRLS

Five levels of severity

• No harm

–Those prevented (near miss)–Those that were not prevented

• Low harm• Moderate harm• Severe harm• Death

NRLS dataset

‘What’, ‘When’, ‘Where’ … and a little ‘How’ & ‘Why’

but NOT Who

notification and basic learning data

hypothesis generating

single high level dataset

specialty extracts

free text to help understanding

data analysis tools

flexibility over time to develop new data fields

stable during national roll out

Overview of analysis of NRLS data

• Routine monitoring reports• Thematic analysis• Ad hoc analysis• Benchmarking information for trusts• Exploratory

– Reviews of selected incidents– Data mining

• The Patient Safety Observatory: analysis of other data sources

Patient Safety Observatory

• Building a memory: Preventing harm, reducing risks and improving patient safety

Number of incidents and reporting trusts

Table of incident reports by care setting

Table of incident reports by degree of harm

Total reported incident types

Who reports:staff type (where known)

No. %

Ambulance staff 738 0.58

Dental staff-general and community 135 0.11

Diagnostic and therapeutic staff 5875 4.62

Manager 4629 3.64

Medical staff 9741 7.67

Nurse/midwife/health visitor 87079 68.53

Optician optometrist 12 0.01

Other 12044 9.48

Pharmacy staff 3050 2.4

Support staff (clinical and administration) 3759 2.96

Total 127062 100.00

Reported incident types

• Acute/hospital sector• Ambulance services• Mental health• Learning disabilities• General Practice

Reported incident types in acute/general hospitals

Reported incident types in ambulance services

Reported incident types in mental health services

Reported incident types in learning disability services

Reported incident types in general practice

Turning information into learning

Reported incident types in acute/general hospitals

Acute incidents: medication process

Medication Process Frequency %

Administration/supply 24791 61.5

Prescribing 6454 16.0

Preparation of medicines 6315 15.7

Other 518 1.3

Monitoring 1778 4.4

Supply or use over the counter 269 0.7

Description of medication incident

Description Frequency %

Wrong/unclear dose or strength 7459 18.5

Omitted medicine 6851 17.0

Wrong drug or medicine 4203 10.4

Wrong frequency 3813 9.5

Wrong quantity 2337 5.8

Wrong/transposed/omitted medicine label

1661 4.1

Bench marking information: feeding back to individual organisations

NPSA Activity Analysis

For

Chief Executive, NHS Foundation Trust

Feedback to individual organisations

• Report available to individual organisation via secure internet site

• Password protected-only NHS organisations can access

NRLS extranet launch

• New service available to all NHS organisations in England and Wales from 2 May 2006

• Each NHS organisation has their own individual report providing a comparison between their data and similar organisations over a 3 month period

• Similar organisations are “clustered” in line with existing definitions

• Reports to be made available quarterly

NHS organisation clusters

• Ambulance• Mental Health• Learning Disability• Primary Care Organisations• Large Acute• Medium Acute• Small Acute• Acute Specialist• Acute teaching

Influencing Role

An Example of Influencing Role –Connecting for Health

• To deliver IT systems which improve clinical safety.

• To provide suppliers with an easy to use and robust safety management system.

• To provide Trusts with assurance and clear guidance on the actions they need to take to ensure systems are deployed in an effective and safe manner.

Requirements

All CfH products and every request to connect with

spine must have:• End-to-end hazard assessment• Safety case• Safety closure report

Must have clinical authority to deploy (issued by Clinical Safety Officer or Director of Knowledge Process and Safety) before products can be accepted into integration testing and deployment

Clinical Safety Organisation

Risk Reduction BoardChair: NHS Trust Clinical Director

NHS CfH Clinical Risk and Safety Team

Chair: Sir Muir Gray

NHS CfH ClinicalSafety Officer

Maureen Baker

Technical AssuranceTest Manager

Project or ComplianceSafety Officer

Clinical Experts

Supplier SafetyOfficer

NHS CfH ProgrammeBoard

Clinical Risk Minimisation

Programme of work to that allows identified safety solutions to be fed into CfH – includes

• Right Patient Right Care• Safer prescribing • Safer handover

As problems identified through NPSA’s Patient Safety Observatory, those with technology solutions can be fed into CfH through this work programme

Embedding SafetyEducational Module for Junior

Doctors

• Aimed at doctors in second foundation year.• Module linked to patient safety learning requirements

in AoMRC’s Curriculum for Foundation Years• Educational material to be available online at

www.saferhealthcare.org• Material will support clinical tutors in Trusts to deliver

module

Content of educational module

• Principles of human error• Principles of risk assessment• Safer systems• Learning from when things go wrong (including

incident reporting and RCA)• Being open• Doctors Net – 39,000 interactions with online

materials on patient safety

Solutions: preventing errors: a hierarchy

Design out the potential for harm

Make incorrect actions correct

Make wrong actions more difficult

Make it easier to discover errors

Preventing errors: a hierarchy

Design out the potential for harm

Preventing Errors: a hierarchy Before After

Solutionsinformation design for patient safety

Good

Bad

Good

Bad

Safe medication practice

• Improving infusion device safety (Safer Practice Notice 02)• National standards for dispensed medicines• Oral liquid medicines and feeds (Design)• Developing a new connector for spinal therapy (Design)• Guidance on safe medication packaging (Design)• Reducing patient safety incidents associated with

anticoagulants• Safer practice with high dose morphine and diamorphine

Solutions / Safer PracticesForms of NPSA advice

• A patient safety alert requires prompt action to address high risk safety problems

• A safer practice notice strongly advises implementing particular recommendations or solutions

• Patient safety information suggests issues or effective techniques that healthcare staff might consider to enhance safety

Learning about falls and use of bed rails

Acute incidents: patient accidents

Patient Accident Incidents Frequency %

Slips, trips, falls 128354 91.5

Collision/contact with an object 6098 4.3

Contact with sharps (includes needle stick)

1519 1.1

Inappropriate patient handling/positioning

1093 0.8

Exposure to cold/heat (includes fire) 1176 0.8

Exposure to hazardous substance 722 0.5

Other 1355 1.0

Not stated 6 0

National Reporting & Learning System: falls

• Analysed random samples of 500 falls in detail in acute settings

Where do patients fall? (n=500)

32%

28%

18%

10%

9%2%1%

fall whilst mobilising

fall from bed

fall circumstancesunclear

fall from chair

fall from toilet orcommode

fall in bathroom orshower

fall other

Falls from bed (n=140)

7%

36%

54%

3%

fall from bed withbedrails

fall from bed definitelywithout bedrails

fall from bed probablywithout bedrails

fall from sitting positionon side of bed

Severity of injury in falls from bed

0

5

10

15

20

25

30

35

40

45

fall from bedwith bedrails

fall from beddefinitely without

bedrails

fall from bedprobably without

bedrails

fall from sittingposition on side

of bed

num

ber o

f inc

iden

ts no harm

low

moderate

severe

death

100 with/100 without bed rails

site of injuries in fall from bed

0

5

10

15

20

25

arm bottom chest head leg/hip spine other

location of injury

nu

mb

er

of

inc

ide

nts

no bedrail

bedrail

Incidents directly involving bedrails

0

5

10

15

20

caught bybedrail

struck bedrail trapped limb other (bedrailfell off onto

foot)

nu

mb

ers

no harm low moderate

Incidents involving bedrails

Learning about the misplacement of

nasogastric tubes

Misplacement of NG tubes:the incident

On Thursday 5th December 2002 an NG tube was inserted to allow

the feeding of an 8 year old girl. The standard tests for placement

were performed and feeding commenced

Unbeknown to all, the tube had been inadvertently inserted through

the trachea and bronchus into the left pleural space

Despite repeated tests the misplacement was not recognised for 24

hours during which time she was fed through the tube

The subsequent chest infection could not be treated adequately and

on 22nd December 2002 the girl died at home

Methods for checking position

• Observation for respiratory distress during insertion• The ‘whoosh’ test

– Insufflation of tube with air whilst auscultating over epigastrium• Testing of NG aspirate for acidity

– Litmus paper – pH paper

• X-ray• Observing ‘bubbling’ when tube placed under water• Experimental methods

– Use of carbon dioxide detectors– Enzymatic analysis of NG aspirate

What had gone wrong?

• Understanding gained whilst writing report for Coroner• Information from:

– Timeline• Constructed by risk management department• Based on physiotherapy records

– Statements– Literature search– Tests carried out on unit

• Two tests used:– The ‘whoosh test’ – Testing of aspirate with litmus paper

Coroner’s recommendations

• Alert Trusts about risks associated with litmus paper• ‘Whoosh’ test to be withdrawn from use• A review of the next edition of the Marsden Manual • Feed manufacturers to be required to show the pH level of their

food• Tube manufacturers to include advice on appropriate tests for

placement• Consideration of a scheme for reporting adverse events and

lessons learnt nationally – National Reporting and Learning System

NPSA involvement

Coroners recommendations based on one case• Patient Safety Managers identified 10 more deaths • Literature review, No test perfect, pH and x-ray most

reliable• Range of 0.3% - 20% misplacements reported in literature • Limited studies in UK, particularly in relation to neonates• NRLS not in operation at the time Potential for aggregate Root Cause Analysis

Aggregate RCA

• Powerful method of determining underlying causes across a number of incidents

• Originally developed in high hazard industries• Advantage - actions taken to improve care are

based on information from a number of events and so are more likely to address common problems.

• Not been done before in UK

Root causes

• Use of unreliable bedside tests

• Limited awareness of risks

• Lack of decision tree

• Lack of competency based training

solution ‘fast tracked’

NG Alert and Carer Briefing

Compliance

• 99% of acute trusts compliant• 85% of primary care trusts

Learning about MRI scanners

MRI scanners and metal: the risks

• Metal within the body, such as pacemakers, could be displaced with fatal results.

• Metallic equipment attached to the patient can malfunction.

• Metal attached to the patient, such as callipers could result in a dislocation or fracture

• Loose metal objects become projectiles, with potential for fatal injury if a patient or staff member is in their pathway.

Starting point

• USA fatalities brought to NPSA attention prior to NRLS rollout

• Professional bodies ‘guidance is in place in the UK’

• UK managers state a problem is ‘extremely rare’

NRLS data

• 526 reports of PSIs in MRI units• 31 of these reports related to implants • Five pacemakers, one implantable

defibrillator, one heart valve and three aneurysm clips went undetected. All of these are potential fatalities.

NPSA observatory

• NHSLA – pacemaker/MRI fatality• MHRA – 200 reports related to MRI• Literature – 14 deaths in other countriesVisits by PSMs • Small projectiles almost everyday occurrence• Frontline staff depending on constant vigilance rather

than safer systems• Significant variations in strength and number of barriers

between units

Proposals

NPSA to work with clinical experts and frontline staff:• To develop patient centred written and visual

information • To scope the formation of a comprehensive register

of MRI compatible materials. • To scope and cost a pilot of additional physical

barriers such as metal detectors.• To improve staff documentation and procedures (e.g.

referral forms and checklists) to take account of human factors.

• To support commissioning for patient safety in MRI

Learning for safer patient

identification

Information from NRLS

• Search on “patient incorrectly identified” = 1506 incidents

Error types

Error types Number

Percent of total

a) Mismatches between patients and the documentation on their samples, records, blood transfusion samples and products, and medication. 975 64.7

b) Missing wristbands or wristbands with incorrect data on them. 236 15.7

c) Mismatches between patients and their medical records. 155 10.3

d) Failures in the manual checking processes. 140 9.3

Total 1506 100.0

Error type by location in acute/general and mental health

Location Mismatches with the

documentation

Wristband use

Mismatches with medical

records

Manual checking process

Ward 329 112 46 53 Laboratory 161 4 4 7 Accident and Emergency 121 15 6 5 Outpatients 78 3 41 19 Radiology 85 14 13 19 Operating theatre 48 39 15 12 General areas 73 18 17 4 Intensive Care Unit 28 14 4 6 Day Care Services 10 3 4 4 Recovery Room 3 8 Anaesthetics 1 Ambulatory Care/ Independent Treatment Centre 1 Therapy 1 Mental Health Unit (ward) 1 Other 14 2 2 2 Total 952 232 153 132

Missing wristbands or wristbands with incorrect data

Specialty No wristband in place Incorrect data on the wristband Totals

Surgical Specialties 29 37 66

Medical specialties 28 22 50

Diagnostic services 25 10 35

Obstetrics and Gynaecology 25 9 34

Accident and Emergency 5 7 12

Dentistry-General and Community 1 1

Anaesthetics 1 1

Other 13 24 37

Total 126 110 236

NPSA patient ID programme

Wristband Safer Practice Notice Nov 2005Identified 236 reports to NPSA of errors concerned with missing or incorrect wristbandsAction for NHS:•Ensure acute hospital inpatients wear wristbands that accurately identify them•Make effective arrangements for implementing and monitoring this action

Solutions work programme:

• Right Patient, Right Care

• Correct site surgery (Patient Safety Alert 06)• Wrist band compliance (Safer Practice Notice 11)• Standardisation of wrist bands• Exploration of bedside checking• Programme of work to reduce the risk of patients receiving the wrong blood during transfusions

Learning from deaths

Crash call trolley incidents – Jan – Feb 2005

• Delay in response to crash call.• No support given by ward staff to patient who had arrested until arrival of crash call doctor.

Door locked/no equipment/ no resuscitation attempted despite no knowledge of patient status re resus.

• Attempt to call crash team to collapsed patient. Subsequently found that crash call phone in switchboard accidentally left off the hook.

• Patient coughing up some bright red blood following radiotherapy. Crash Team call. Apparatus missing from crash trolley/emergency lights not working/insufficient staff to cope with the situation.

• Patient suffered cardiac arrest. Crash trolley found not to have been replenished with essential drugs following previous use.

• Equipment on crash trolley was incomplete rendering it unusable and delaying the ability to remove vomit of patient to obtain a clear airway.

• Cardiac arrest call. Incomplete equipment on crash trolley meant unable to provide appropriate care.

• Patient collapsed whilst on commode in community. Dr called and declared patient dead. After doctor left patient found to be alive. Crash team called.

• 2 PSIs for same incident. Patient’s condition declined to cardiac arrest without appropriate monitoring or outreach team being called.

Example of NRLS/PSO -tracheostomy

• Clinical concern re transfer from ICU to general wards• NRLS: 36 incidents, one death• NHSLA: 45 litigation claims Feb 96 to April 05, of which 13

related to the management of tracheostomy tubes, including 7 deaths

• MHRA: 10 similar incidents since 1998 • HES: increase in tracheostomies being performed in the last 5

years, and a higher proportion of patients who have had a tracheostomy being cared for outside of surgical and anaesthetic specialties

• NPSA Bulletin• Scoping work with other organisations

NRLS: other examples of analysis and issues identified

• patient ID problems in lab tests – lab results or samples being mis-identified• non-medical devices/IT equipment – errors or failure of computing and other

non-medical equipment leading to incidents• missed/delayed diagnosis – incidents relating to this, particular in

emergency care• infusion pumps – inappropriately attaching an infusion pump line to an

intravenous line• pre-filled syringes – supply problems of emergency pre-filled syringes• oxygen cylinders – people smoking near use of oxygen, cylinders falling on

people• bleeps not working, leading to failure to respond to urgent calls• Fire and burn risk from skin preparations and diathermy• Swabs missing from surgery

Summary of ambulance NRLS data 1/4/05 – 30/06/05

• Patient accident (33%)– Injury from vehicle steps– Instability of trolleys and chairs– Patient falling

• Access/admission/transfer/discharge (29%)- OOH care- Transfer of Care

• Consent/communication/confidentiality (11%)- Prioritisation of calls

• Medical device/equipment (11%)– Defibrillator failure

• Treatment procedure (5%)• Consent, communication, confidentiality (3%)

Are we learning from these tragedies?

Patient Safety Alert Impact

Potassium Chloride

Patient Safety Alert 01(2002)

• 100% reduction in deaths since 2002• 97% uptake of actions

Crash call

Patient Safety Alert 02 (2004)

• Survey in 2002 indicated 27 different numbers being used for crash calls across 173 trust

• 100% compliance. All trusts using 2222

Methotrexate

Patient Safety Alert 03 (2004)

• 87% of GP practices have implemented safety alert

Cleanyourhands

Patient Safety Alert 04 (2004)

• 99% of trusts in England and 100% of hospitals in Wales implementing cleanyourhands campaign

Nasogastric Feeding Tubes

Patient Safety Alert 06 (2005)

• 99% of acute trusts in England have implemented this notice.

Correct Site Surgery

Patient Safety Alert 06

• 70% of acute trusts in England have completed the actions and 38% of acute trusts in Wales

Evaluation and Impact

NHS Health Organisations - The Road to Resilience

Proactive Risk

Assessment Toolkits

Scenario Based

Decision Making

Foresight Training

Vulnerable – High Reliability - Resilience

8,000 NHS staff trained in Root

Cause Analysis

7 Steps to Patient Safety

General and Primary Care

Chief Exec Checklist and

Board Training

National Reporting and

Learning System

Cultural ToolsBeing Open

MaPSaF

Incident Decision

Tree

FeedbackPSO -

BulletinExtranet

Patient & Public

Reporting

The Challenges Faced

The Future

NHS Health Organisations - The Road to Resilience

Proactive Risk

Assessment Toolkits

Scenario Based

Decision Making

Foresight Training

Vulnerable – High Reliability - Resilience

8,000 NHS staff trained in Root

Cause Analysis

7 Steps to Patient Safety

General and Primary Care

Chief Exec Checklist and

Board Training

National Reporting and

Learning System

Cultural ToolsBeing Open

MaPSaF

Incident Decision

Tree

FeedbackPSO -

BulletinExtranet

Patient & Public

Reporting

“A structured systematic means for ensuring that both general and particular aspects of what the organisation does are effectively managed to meet the high standards of safety.”

Reference: Waring A (1996) Safety Management Systems. London: Chapman

and Hall

Senior Management Commitment

• Safety is a primary goal of the organisation.• Senior management has the ability to drive safety

systems.• Identified person(s) to take responsibility.• Open communication about safety issues.• Appropriate resource allocation to address concerns.• Integration of safety with other management

systems.

A Proactive approach to Risk• Formal and informal meetings about safety.• Risk assessments considered a part of every day working

practices.• Integration of known risks and potential risks incorporated into a

register for all risks (a risk register).• Links between the risk assessment process and business

performance.• A clear understand of how those risks can be managed through

defences and controls.• Solutions to minimise risk.• Changes to procedures to work around the risk.

• Communication about risks to staff and public alike.

Reactive Processes

• Open and fair culture.• Confidential reporting systems.• Feedback on information and action taken.• Incident analysis used to identify conditions which

need correction – informing risk assessment processes (moving from reactive to proactive approach).

Accountability and Follow Up

• Risk registers translated into action plans.• Action plans describe specified accountability.• Risk register and action plans (and risks themselves)

are monitored and reviewed through audit processes.• Formal assurance processes to show that reporting

goals have been achieved.• Feedback.

NPSA Guidance

Safety Check List

Senior Management Commitment

Proactive Approach to Risk

Reactive Processes

Accountabilityand Follow up

Safety Management System

Delivering safer healthcare –A leadership checklist for NHS Chief

Executives

“…The ability of a system or organisation to react to and recover from disturbances at an early stage, with minimal effect on the dynamic stability.”

Reference : Hollnagel E, Woods D and Leveson, N (Eds). Resilience Engineering. Ashgate Publishing, in press, due for publication January, 2006.

How do Staff

• Prevent something bad from happening?• Prevent something bad from becoming worse?• Recover from something bad once it has happened

to minimise harm?

Reference: Westrum R. Being resilient. In: Hollnagel E, Woods D and Leveson, N (Eds). Resilience Engineering. Ashgate Publishing, in press, due for publication January, 2006.

Reference: Reason, 2005

Features of Local Safety UnitsIt is proposed that each unit:• is integrated into the Chief Executives network in the Health Authority;• works closely with the Strategic Health Authority to ensure patient safety is

core to the targets for Trusts and the performance management and improvement work;

• is aligned with a University Department(s) conducting research into safety;• has expertise in human factors and design;• has resources to provide training in the fundamentals of patient safety;• delivers the ‘Patients for Patient Safety’ initiative locally;• takes the lead nationally for a particular area such as mental health,

vascular surgery or general practice (as has been the model with Public Health Observatories);

• develops solutions to local safety problems and disseminates these across all Units;

• engages experts from safety conscious industries in the area to transfer expertise from these industries into healthcare;

The following diagram sets out the different elements of a programme for a health community:

Strategic Health Authority: agreement of role and remit, including how support can be accessed across an area (eg: local safety units)

Pro

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*

Board and senior manager programmes – some specific to the organisation, some generic across organisations

Organisational programmes – some specific to the organisation, some generic across organisations

Clinical safety programmes designed to address specific safety issues in each organisation (eg: eliminating central line infections or preventing patient suicides)

Clinical safety programmes designed to address issues across and between organisations (eg: discharge summaries or medicines reconciliation)

Support from safety experts in other local industries

*KSF – Knowledge and Skills Framework

Patient Safety at National Level – Functions at a National Level

• Bearing in mind the criteria above, we believe that there are a number of functions that should continue to be discharged at a national level, at least in the medium term.

• managing the national reporting and learning system. The WHO guidelines for adverse event reporting and learning systems state that the system must be confidential and safe for the individuals who report and reporting must lead to a constructive response. It is important that these principles continue to be reinforced;

• developing robust mechanisms to provide regular reports back to both organisations and the public about the information collected, demonstrating learning from reports and facilitating the spread of knowledge and solutions developed at a local level;

• drawing together information on risks in the health care system to inform future direction, priorities and action through the Patient Safety Observatory;

• influencing health service policies at a national level to enable safety to be embedded across all policy areas for example CfH, HR, finance, regulation, development of educational curricula and performance management;

• coordinating work across a range of national organisations with key roles in safety – e.g. Royal Colleges, other ALBs.

Patient Safety at National Level – Functions at a National Level – cont’d

• influencing national initiatives such as purchasing and information technology;

• influencing at the EU level in areas such as the free movement of professionals, the regulation of drugs and healthcare devices;

• providing expert advice distilled from a wide range of safety conscious industries and university departments and translating this into the healthcare setting;

• influencing healthcare industries to improve safety including drugs and medical devices;

• developing tools and techniques to support staff across the NHS in delivering the fundamentals of patient safety, such as the ‘Seven Steps to Patient Safety’, the RCA toolkit and prospective risk assessment methods;

• developing methodologies for involving and engaging with patients and the public on patient safety;

• developing national solutions, for example the Potassium Chloride Alert, which required work at a national level with the pharmaceutical industry to ensure that diluted product was available across the NHS;

Features of a National Function

• organisational values aligned with the ‘open and fair’ culture associated with successful safety systems;

• trusted that reports will be used for learning rather than for punitive purposes;

• sufficient authority and independence to publish data and learning in a timely and regular fashion;

• credibility with patients and the public;• linked with local safety units, with mechanisms for

them to be formally represented within the national function;

• governance arrangements that facilitate stronger ties with and buy-in from national and local stakeholders.

SummaryNow that the NRLS is in place and many of the building

blocks of a safety system have been developed, if not

yet fully embedded, we believe that we have a reached

a point where it is appropriate to enhance the skills and

resources for patient safety at an intermediate and local

level. Alongside this there remain major national roles to

both support and encourage local delivery and to provide

national leadership and action where there is clear benefit in

national delivery, policy and influence but……..

Implementing Patient Safety Programmes – the story no one ever

wants to tell!

Expert Seminar - Paris

22 – 24 May 2006

www.npsa.nhs.uk