Seven steps to patient safety: A route

map to delivering a safer health care

system in England & Wales

Susan Williams
Joint Chief Executive
National Patient Safety Agency
 Overview

Patient safety what, why and how big is

the problem in the UK

Role of National Patient Safety Agency

Seven steps to patient safety and the tools

to make a difference
 Patient Safety A global issue
18
16
14
Australia 16.6%
12
England 10.8%
10
Denmark 9%
8
New Zealand 12.9%
6
Canada 7.5%
4
Japan 11%
2
0
% of acute admissions
 Patient Safety A National Issue
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
 Patient Safety A Local Issue
A typical acute hospital with 500 beds

No. of Admissions 30,000

No. of PSIs 3,200
Moderate to severe 1,100
Preventable 1,500
No. of extra bed days 27,400
Cost 7.4m
Number of claims p.a 20
Settlement payments 1.2m

Sources: DOH, HES and Activity States 2002, NHS Negligence claims CNST, Vincent et al.
2001
 UK Context

Organisation with a
Memory 2000
Building a Safer NHS 2001
Bristol Enquiry July 2001
Nottingham January
2001
 What is the
National Patient Safety Agency?
 advise Ministers

promote R&D

track progress

develop NHS-wide solutions

assimilate information from others

capture and analyse incidents

 Purpose of the 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 care
 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
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
Openness with patients fair for all staff
Incident Decision Tree
 Balancing individual v- system error
Individual approach Systems approach
error prone people - error prone situations -
individuals are careless, at poor organisational design
fault, reckless sets people up to fail

Find someone to blame Focus on multiple

punish, shame and train contributing factors not
just actions of individual

Fix individual = improve Redesign the process =

safety improve safety
 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
 Application of human factors
Relying too much on human memory
Solution: decision aids, electronic alerts, checklists
Poor communication between members of the team
Solution: team briefing and de-briefing
Vulnerable handover points across care boundaries
Solution: clearly identified roles and responsibilities
Wide variety of equipment in use
Solution: standardisation where relevant
Inadequate orientation / induction / rehearsal
Solution: rehearsal simulation training, induction training
 Step 2
Leadership 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
Levels of maturity with respect to a safety
culture

Risk
management
is an integral
We are
part of
always on
We have everything
the alert for
systems in that we do
risks that
We do place to might
something manage all emerge
Why waste when we like risks
our time on have an
safety? incident

Pathological Reactive Calculative Proactive Generative

Commitment to Q

Priority to PS

Causes

Investigation

Learning

Communication

Personnel

Education

Team working
Patient safety e-learning
programmes
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
 Step 4
Promote 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)
National Reporting & Learning System
electronic system to enable NHS organisations
and staff to report patient safety incidents to a
national database in order to:
analyse and report on data
encourage improved reporting
help the NHS learn from errors and system
failures
build a more open and fair culture in the NHS
 Prevented, i.e.
NPSA Definitions not impacted on
patient (previous
NO HARM near miss)
PATIENT SAFETY
Not prevented,
INCIDENT
but resulted in
Any unintended or LOW
no harm
unexpected incident(s)
which could have or
did lead to harm for MODERATE
one or more persons
receiving NHS
funded care SEVERE

DEATH
 Design of the Reporting System
anonymous (patients and staff)
confidential (NHS organisations)
voluntary
hypothesis generating and learning
complement not replace local reporting
build on local risk management systems
streamline impact at frontline
patient and public reporting (over time)
 Research by NPSA PRIORITISATION
-With others Patient Safety Research -Criteria/methods
-Lit review -(rapid response)
-Topic selection
OTHER ORGANISATIONS
CHAI, DoH etc
NRLS

Other bodies & Their views

Surveillance Public/Patient e-form
SHAs &
NICE Monitoring EVALUATION
DoH/Ministers
CMO OBSERVATORY Other confidential reporting
CPPIH systems
VOs/Charities
R&D

Other dataset relevant to

NHS Feedback Sources of patient safety
& Bounceback Intelligence/Knowledge e.g. MRHA
-CSAs, PSMs & Expert Groups NCAA
-PEPI & Patient/Public Views PATIENTS/ CHAI Reviews
-Individual Patients PUBLIC HES
-Interest Groups etc. RCGP Database
NHS Direct
 Results

Hospital system (DA) CICU consultants

system(DB)

68 44 99
Both

Ricci, Goldman, de Leval, Cohen, Devaney and Carthey 2004

Local Risk Service Service Public
Management
eForm eForm eForm
System

WWW
NHS Net

Encrypted
traffic Feedback
Feed
Back Web
national Pages
trends

National Reporting and Learning System

Analysis

Secure Anonymisation Cleansed

Database
Database
 National reporting and learning system

NHS
NRLS reports

monitor
impact Improved
patient
safety

test & design identification of issues

implement solution prioritisation of solution work
solution
eForm Look and Feel
SAS 3D Bar Chart
SAS Control Chart
Autonomy Cluster Map
dining room, door, tv
126 documents
Found on floor beside bed.
Found on floor between bed and commode.
Found on floor by sluice.
Patient was attempting to get out of bed to commode when his feet slipped
and
Patient walking with walking aid in dining room - loud crash. Patient fallen to
ground
While walking from one dining area to the next, patient tripped over door
threshold resulting
Patient attempting to throw tv, alarm activated, several staff attended and
intervened, there were other

While attempting to get up and stand at the side of bed patient slipped onto
Patient sound on floor, says he slipped of bed.
Patient had been on commode he said he stood up without asking for
assistance and
cord Ph, baby, paed
60 documents
Patient readmitted to CHDU following transfer to ward area from [Ward
name].This patient was readmitted
Baby born NVD - Cord ph 6.94. Apgars 7,10. Paed SHO informed - to observe
Low cord Ph's
Low cord ph's 7.185 + 7.177
NVD with normal CTG's during labour - clear liquor. Cord pH 7.052
Baby born and did not establish regular respirations and was put on the
resuscitaire and
Uneventful labour. Caesarean delivery with cord round neck. Slipped over at
the time cord Ph
NVD at 36/40. Paed called to review baby who was grunting advised to
observe. Baby
Mother had IOL for obstetric cholestasis. ARM - meconium stained liquor. Baby
Ph 7.06, 7.132
 Lucien Leape

To understand an adverse event and

prevent future problems requires analysis.
You have to examine, investigate and talk
to people.
 Step 5
Involve and communicate with patients
and the public
Being open principles
Apologise and explain
Find out the causes
Offer support in coping with the consequences
Advise about ongoing treatment required
Involve patient and carer in the investigation and
the recommendations for change
 NPSA Being Open Toolkit
Policy
What to say, who should say it and when
Video
Case studies to demonstrate communicating bad news
Training programme
Groups of 16 using actors to role play scenarios
E-learning
To be available on the www 2005
 Step 6 Learn and share safety lessons

Root Cause A structured, robust

approach to incident
Analysis investigation which looks
beyond the immediate
actions and assumed
causes and identifies the
contributory factors, latent
conditions and root causes
which lead to an incident
occurring.
 NPSA RCA programme
Over 5000 NHS staff trained in RCA
methodology
E-learning toolkit
Guidance
Aggregated themed RCA
RCA data capture
Training for independent investigations
Individual factors
 Step 7
Solutions 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 doesnt work

Affordances How would you operate these doors?

Push or pull? left side or right? How did you know?

A B C

John R. Grout
 What Can Be Done
to Remove Problems ?

Design out the problem

Change the system
Change practice
Train the staff
Involve patients
 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
NPSA Patient Safety
Alert 1:
Preventing
Accidental Overdose
with Intravenous
Potassium
 Summary of Safety Controls for Potassium Chloride Solutions
Before and After Safety Alert

100%
87%

75% 69%
Positive Responses %

Before Alert
50% 2002 (n=172)
2003 (n=154)
25%
25%

0%
Time of data sample
 Case Examples

Cleanyourhands campaign
Hand hygiene and compliance according to risk category and
observation period
(the size of the symbol is proportional to the number of opportunities observed)

120%

100%

80%
Compliance

60%

40%

20%

0%
May-03 Jun-03 Jul-03 Aug-03 Sep-03 Oct-03 Nov-03 Dec-03 Jan-04
Observation Month

Low Risk Medium Risk High Risk

Linear (Low Risk) Linear (Medium Risk) Linear (High Risk)
Patient safety incidents with oral
methotrexate 1993-2002
70
60
50
40
T otal
30 Harm
Death
20
10
0
prescribing lack of dispensing other causes
the wrong monitoring error
frequency

137 cases, 25 deaths

 Improving Labelling and Packaging

A partnership with
UK manufacturers
of Methotrexate to
develop novel
packaging designs
 Alerts in clinical IT systems

A project to adapt IT
systems in GP
surgeries and
community
pharmacies to
incorporate flagging
mechanisms to
provide alerts
 Improving Infusion Device Safety
Average per hospital
31 different types
1065 pumps in stock
65% lying about under utilised

Potential cost savings by

standardizing equipment and
creating a central store:

161,667 per hospital

33.7 million across NHS
 To err is human
To cover up is unforgivable
To fail to learn is inexcusable

Sir Liam Donaldson

Chief Medical Officer
England
Thank you for listening

Any questions?

Need help contact; www.npsa.nhs.uk