Safer Systems for Safer Healthcare

1
Safer Systems for Safer Healthcare

• Dr. Maureen Baker CBE DM FRCGP
• Clinical Director for Patient Safety
• NHS Connecting for Health

2
Overview

• The NHS
• The NPfIT
• Development of patient safety movement
• Safety management systems
• NHS CFH Clinical Safety Management System
• Experience so far
• Next steps

3
The UK National Health Service

• UK population 60 Million
• Almost 1 Million consultations with GPs every
  working day
• 100,000 people in hospital every working day
• NHS covers every health sector
• 4 country model
• 750 Million prescription items from general
  practice in England per annum

4
The National Programme for IT in the NHS in
England

• Established 2002
• Has a number of central features and programmes
  (National Spine Choose and Book GP2GP National
  Care Record Service Picture Archive and
  Communications Service Electronic Transfer of
  Prescriptions)
• Local Service Providers
• Estimated cost US25 Billion over 10 years
  (contracts, training and implementation)
• Being delivered by NHS Connecting for Health

5
Some definitions

• Patient Safety freedom from accidental harm
  to individuals receiving healthcare
• Patient Safety Incident an episode when
  something goes wrong in healthcare resulting in
  potential or actual harm to patients

6
NPSA Report on Safety in NPfIT

• National Patient Safety Agency established 2001
• Report commissioned 2004
• Conducted by NPSA Risk Advisor

7
Report Findings

• Not identifying safety as a benefit to drive the
  programme
• No formal risk assessment
• No formal safety management system
• Reliance on clinicians to instinctively address
  patient safety problems
• NPfIT not addressing safety in structured,
  pro-active manner and other safety critical
  industries would

8
Safety Critical Industries with Safety Approach
Aviation Railways Oil and Gas Construction Nuclear
Military
9
NHS CFH Clinical Safety Management System

• Based on principles of IEC 61508
• Light touch, yet robust
• Three key pieces of documentation
• Practical and pragmatic in place for almost 4
  years
• Supplemented by established Safety Incident
  Management Process

10
NHS CFH CSMS Deliverables

• Hazard assessment
• Safety case
• Safety closure report
• Clinical Authority to Release (CATR)
• (Includes caveats)

11
What we are trying to achieve?

• Safer Care, i.e.
• x gt y ab

Risk
Baker, M et al, Safer IT in a Safer NHS Account
of a Partnership, The British Healthcare
Computing Information Management, Vol. 23 No. 7
Sept 2006
12
Safety Incident Management System

• Incidents related to Health IT reported and
  logged
• Assessed and managed by Clinical Safety Group
  (clinicians and safety engineers)
• Aim to make safe (remove potential for harm)
  with 24 hours
• Around 430 incidents reported since 2005
• 97 made safe within 24 hours

13
NHS IT What can go wrong?

• Patient identification (wrong notes, wrong
  results, wrong procedure)
• Data migration (re-start discontinued drugs,
  incorrect preservation of meaning)
• Data mapping (mapped to non-identical
  preparation, eg long-acting or slow release)
• Data corruption (over-writing of info on NHS
  Spine)

14
Safety Workstreams in NHS CFH

• Safe IT systems (as safe as design and
  forethought will allow)
• Safety Incident Management Process
• Training for accreditation and safe
  implementation
• Technology for patient safety

15
Accredited Clinician Programme

• Dedicated training in principles of safety and
  risk as applied to Health IT
• In 4 years trained over 550 delegates, approx
  60 are clinicians
• Clinicians must be registered with appropriate
  regulatory body
• Supports clinical input to activity by
  appropriately trained and qualified clinicians

16
Passing the Safety Baton

• NHS CFH (and Software Providers)
• Support from
• Clinical Safety Group
• Clinical Authority to Release

• Implementing organisation (Hospitals Pharmacists,
  GPs etc.)
• Support from
• Internal Risk Team

Safer Design and Development
Safer Implementation
Passing the Baton Ownership passed from NHS CFH
to NHS
17
Implementation Network

• Aimed at individuals in NHS Trusts with direct
  responsibility for significant IT implementations
• Develop a community of interest
• Explicitly designed to facilitate networking and
  peer support
• Dedicated website
• Buddying
• Could be used in support of User Standard

18
Technology for Patient Safety

• Right Patient Right Care (tracking technologies
  RFID wristband datasets NHS number)
• Safer prescribing (prompts alerts, tallman)
• Safer handover (core dataset)
• Electronic risk assessment tool for VTE
• Tracking of results
• Deteriorating patients

19
Design and the NHS
The NHS is seriously out of step with modern
thinking and practice with regards to design .
And also fails to understand what design thinking
can bring to an organisation . A direct
consequence of this has been a significant
incidence of avoidable risk and
error Department of Health Design Council,
Design for Patient Safety Report
20
Building a House
21
Next steps

• Focus on design and human factors for inherently
  safe systems
• Support implementation of standards (NHS and
  international) for suppliers and users
• Passing the safety baton
• Identification and safe implementation of
  technology for safer care

22
National Programme for IT in NHS
The National Programme is not just an IT
programme, but a patient safety and clinical
governance programme Gordon Hextall, Chief
Operating Officer NHS Connecting for Health
23
Conclusion

• Healthcare is a safety critical industry
• IT systems dont deliver care, but are used by
  clinicians in the delivery of care
• Good safety practice requires proactive work
  systems as safe as design and forethought will
  allow
• Also reactive systems to detect and manage errors
• All encompassed in CSMS and within emerging
  Standards