Oxford AHSN Patient Safety Collaborative

November 2014

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What is patient safety?• Broadly the reduction of harm

• Incident? Adverse events?• Or major failures in care with implications for patients?• Or the risk of such events?

• Building a safer system• Safety as an aspiration in a hazardous environment• This has implications for what we do and how we

approach the programme

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Oxford Region Partnerships• Patients and carers• Patient Safety Federation• South of England Mental Health & Community

PSC• Patient Safety Academy• AHSN Partners – Universities, NHS and

Industry

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Oxford AHSN Patient Safety LandscapeSepsis/ Infection

Medicines management

Human Factors

Avoidable Harm/ Death

Falls Prevention

Malnutrition

Board engagement

Patient Experience

Pressure Ulcers

UTI prevention

Patient Safety FederationP P P P P P P

South of England Patient Safety in Mental Health Collaborative P P P P P PPatient Safety Academy P P POxford AHSN Clinical Networks P POxford AHSN Clinical Innovation Adoption programme P P P P POUHT POHFT P P PBucks New University P P POxford Brookes University

PUniversity of West London

P P4

Prioritisation• Sources:

• National priorities (essentials – assume this is leadership and measurement)

• Local priorities (Trusts, commissioners and clinical networks) chosen from:• Falls• Pressure ulcers• Nutrition and hydration• Acute kidney injury• UTIs and other infections• Missed and delayed diagnosis• Failure to return to mental health wards• Deterioration of patients• Medication safety• Sepsis• Handover & discharge

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Prioritisation• Sources:

• National priorities (essentials – assume this is leadership and measurement)

• Local priorities (Trusts, commissioners and clinical networks) chosen from:• Falls• Pressure ulcers• Nutrition and hydration• Acute kidney injury• UTIs and other infections• Missed and delayed diagnosis• Failure to return to mental health wards• Deterioration of patients• Medication safety• Sepsis• Handover & discharge

• Process to agree future priorities6

Measurement & Evaluation• Our major challenge will be to demonstrate change (rather

than activity)• This has bedevilled all safety programmes in NHS• Measurement is therefore number 1 priority because:

• It focuses minds and priorities• It has been the major headache for all safety programmes• The time taken to get measures in place has been consistently

underestimated• It is essential for the programme teams to function effectively• It is fundamental to evaluation

• We should not initiate any programme in early phase unless measures are already available

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Types of safety initiative

• Clinical topic programmes • Thematic clinical programmes which address issues which

cross the best care programmes (e.g. handover, transitions etc)

• Thematic programmes which address organisational and system level issues (e.g. regulation)

• And others ….• In the longer term we need to build a safer system

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