Preventing harm, reducing risks and improving patient safety

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Preventing harm, reducing risks and improving
patient safety

• Suzette Woodward
• Deputy Director of Safer Practice

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NHS

• National Health Service
• Complex, size, diversity and geography
• Worlds third largest employer
• Behind the Chinese Army and the Indian Railway
  Industry
• Increasingly technology driven
• Problems with capacity, capability, variation,
  cost and time pressures
• All impact on patient safety

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Patient Safety A global issue
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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
• gt450 million clinical negligence settlements
• over 1 billion spent on hospital associated
  infections
• 29 million direct costs related to staff
  suspension

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What costs are we talking about?

• Patient
• pain, suffering, lost income, time
• Organisation
• increased length of stay, additional therapy and
  treatment, negligence claims, loss of reputation
• Health System
• additional treatment across the system,
  rehabilitation, longer waiting lists, reputation
• Wider Society
• health care expenditure, lost production, loss of
  taxation, decreased spending

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Increased costs due to

• Harm
• Patient safety incidents / adverse events
• Complications and side effects
• Out dated care and inefficiencies
• Unnecessary activity both clinical and admin
• Over-use of therapy and treatment
• Antibiotics, sedatives, endoscopies, scans
• Under-use of therapy or treatment
• Diagnostic tests, screening tests
• Complaints and litigation and staff time

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Background

• An organisation with a memory
• Building a safer NHS for patients

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advise Ministers
promote RD
track progress
develop NHS-wide solutions
assimilate information from others
capture and analyse incidents
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From 1 April 2005

• NPSA assumed responsibility for
• National Clinical Assessment Service
• (NCAS - formerly NCAA)
• Central Office for Research Ethics Committees
  (COREC)
• Safer food, cleaning, some aspects of hospital
  design
• Contracts with confidential enquiries
• (formerly with NICE)

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Functions of NPSA

• Safer Systems
• Including clinical systems, cleanliness and
  nutrition
• Safer Practices
• Safer Environment and Design
• Safer Research
• Safer Culture
• Safer Practitioners

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Patient Safety Journey

• Risk management introduced to healthcare through
  standards to reduce clinical negligence claims
  1994
• Risk management became one of the Clinical
  Governance themes
• Risk management recognised to encompass health
  and safety and patient safety
• Patient safety a separate focus as a result of a
  review by the Chief Medical officer

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Key initial stages

• 1995 NHS Litigation Authority - Risk Management
  Standards
• 1997 NHS Modern and Dependable Government
  White Paper - Increased profile of quality
• 1998 Dept of Health A First Class Service
  Quality in the new NHS - Clinical Governance
  introduced
• 1999 Dept of Health - Controls Assurance
  Standards

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7 themes of clinical governance

• Patient and Public Involvement
• Risk Management
• Staff Management
• Training and Development
• Information Management
• Clinical Audit
• Clinical Effectiveness

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Key organisations

• National Institute of Clinical Excellence (1999)
• Clinical effectiveness
• Commission for Health Improvement (1999)
• Regulation and Inspection
• Became Healthcare Commission (2004)
• National Patient Safety Agency (2001)
• Guidance, support, interventions
• National Institute of Improvement and Innovation
  (2005)

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Key documents

• 2000 An organisation with a memory
• 2001 Bristol Royal Infirmary Inquiry Report
• 2001 Building a Safer NHS
• 2002/05 Shipman Inquiry Reports
• 2004 Seven Steps to Patient Safety
• 2004/05 Standards for Better Health

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Healthcare Commission
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Standards for better health

• safety
• clinical and cost effectiveness
• governance
• patient focused
• accessible and responsive care
• care environment and amenities
• public health

• Core standards must do now
• Developmental standards - aspirational

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Safety Management Framework for the NHS

• Seven Steps to Patient Safety
• For all care settings
• Focused for primary care
• Checklist for chief executives
• Non-executive training
• Clinical leaders training

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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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www.npsa.nhs.ukwww.saferhealthcare.org
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Thank you for listening

• Suzette Woodward
• Deputy Director of Safer Practice