Download - The Work of the National Patient Safety Agency Joan Russell Safer Practice Lead-Emergency Care
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The Work of the National Patient Safety Agency
Joan Russell
Safer Practice Lead-Emergency Care
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Overview
• Patient safety – what, why and how big is the problem?
• Seven steps to patient safety and the tools to make a difference
• Ambulance Service Risk Assessment
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Patient Safety – A global issue
0
2
4
6
8
10
12
14
16
18
% of acute admissions
USA 3.7%
Australia 16.6%
England 10.8%
Denmark 9%
New Zealand 12.9%
Canada 7.5%
Japan 11%
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Cost of unsafe care each year in the UK…
• 10% of admissions = 900,000 patients affected
• around £1 billion/year in extra hospital stay costs
• average 8.5 extra bed days
• 400 people die or are seriously injured in incidents involving medical devices
• >£450 million clinical negligence settlements
• over £1 billion spent on hospital associated infections
• £29 million direct costs related to staff suspension
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Background
• An organisation with a memory
• Building a safer NHS for patients
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Seven Steps
1. Build a safety culture that is open and fair
2. Lead and support your staff in patient safety
3. Integrate your risk management activity
4. Promote reporting
5. Involve patients and the public
6. Learn and share safety lessons
7. Implement solutions to prevent harm
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Step 1 - Build a safety culture that is open and fair
• Safety is considered in everything you do
• There is a balanced approach when things go wrong - you ask why and not who
• Constant vigilance
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PATIENT SAFETYINCIDENT
Any unintended orunexpected incident(s)
which could have ordid lead to harm for
one or more personsreceiving NHS
funded care
NO HARM
LOW
MODERATE
SEVERE
DEATH
Not prevented,but resulted in
no harm
Prevented, i.e.not impacted onpatient (previous
near miss)
NPSA Definitions
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Patient safety e-learning programmes
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• the perfection myth
– if we try hard enough we will not make any errors
• the punishment myth
– if we punish people when they make errors they will make fewer of them
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Incident Decision Tree
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Step 2Leadership and support
Leadership advised to:• Undertake executive walkabouts• Develop team safety briefing and debriefing • Appoint patient safety clinical champions• Undertake safety culture and team culture
assessments
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Step 3 - Integrated risk management• all risk management functions and information:
–patient safety, –health and safety, –complaints, –clinical litigation, –employment litigation, –financial and environmental risk
• training, management, analysis, assessment and investigations
• processes and decisions about risks into business and strategic plans
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Step 4Promote reporting
• National reporting and learning system (NRLS)• Reporting via:
– local risk management systems– E-form on NHS net– E-form on www
• Anonymous (names of patients and staff)• Confidential (names of organisations)
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National reporting and learning system
NHS
NRLS
identification of issues prioritisation of solution work
design solution
test & implement solution
Improved patient safety
monitor impact
reports
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Step 5Involve and communicate with patients
and the public
Being Open
Ask about medicines leaflets
SPEAK UP
Involve in investigation
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Step 6 Learn and share safety lessons
• NPSA Root Cause Analysis Programme
• Over 5000 NHS staff trained in RCA methodology
• E-learning toolkit
• Guidance
• Aggregated themed RCA
• RCA data capture
• Training for independent investigations
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Step 7Solutions to Prevent Harm
• Address root causes• Make designs of equipment, systems, processes,
more intuitive• Make wrong actions more difficult• Make incorrect actions correct• Make it easier to discover error
“Telling people to be more careful doesn’t work”
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Ambulance Service Risk Assessment
• To identify existing risks at each stage of the emergency response process
• To identify possible risk solutions for high risk issues• Develop a solutions programme of work
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Process
• Identification of risks• Identification of causes, consequences and controls • Prioritisation of risks• Identification of solutions• Re-evaluation of risk• Cost/time effectiveness
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Key Themes
• Prioritisation/triage• Health Care Associated Infection• Managing Demand• Transfer of Care• Equipment Design
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Patient safety observatory and prioritisation processPatient
Safety Info
PSO
NRLS and
other data
sources
Filtering of submissionsNPSA Board
NPSA work programme
submissions
Expert Advisory Panel
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John R. Grout
How would you operate these doors?
BA C
Affordances
Push or pull? left side or right? How did you know?
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Which dial turns on the burner?
Natural Mappings
Stove A
Stove B
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What Can Be Done to Remove Problems ?
• Design out the problem • Change the system • Change practice • Train the staff• Involve patients
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• Design out the problem(design solution)
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Clear design
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Case Examples
Cleanyourhands campaign
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Forms 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
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1st team of engineers…
Task-‘replace centre console light panel around the throttle quadrant’
• Throttle levers in full power position
• Take-off warning horn silenced
• Circuit breaker pulled
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Next engineer…
Task-‘trouble shoot a reported engine oil quantity discrepancy’
Requirement of task-undertake an engine run
Guidance-’Pre Power On’ Taxi/Towing Checklist
• Check circuit breakers
• Throttle levers to idle
• Parking break set
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To err is humanTo cover up is unforgivable
To fail to learn is inexcusable
Sir Liam Donaldson
Chief Medical Officer
England
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Thank you for listening
Any questions?
Need help contact; www.npsa.nhs.uk