The NPSA role includes…. and the report concentrates on three key areas: First, it reports on early data from our National Reporting and Learning System Second it describes how we bring together data from the NRLS and a range of other sources to understand and characterise patient safety issues Third it gives examples of how data from these sources is of value in helping us to make the NHS safer.
Evidence from case note review studies that incidents are under-reported, even to well established system
No-one source is likely to address all of these – we are likely to need a number of sources. Describe the NPSA approach to this… [include local picture of this] So – where does incident reporting fit in?
At a local level, likely to be many sources too – with different strengths and weakness
NPSA’s role in complaints
NPSA’s role in complaints
Failures in standards of care DYSFUNCTIONAL POOR SERVICE PRACTITIONER PERFORMANCE SYSTEM WEAKNESSES SUBOPTIMAL SERVICE DELIVERY
Healthcare ResponsibilitiesCommission National Clinical Assessment Service DYSFUNCTIONAL POOR SERVICE PRACTITIONER PERFORMANCE PATTERNS & SYSTEMS SUBOPTIMAL SERVICE DELIVERYNational PatientSafety Agency Trust Boards and Strategic Health Authorities
Purpose of the NPSASpecial health authority with mandate to: – implement a national reporting system for patient safety incidents – collect and appraise information to promote patient safety – provide advice and guidance and monitor its effectiveness – promote research which contributes to patient safety – report and advise Ministers on matters affecting patient safety
Vision for NPSA Creating a Safer NHSCurrent Position Future PositionBlame the reporter Praise the reporterKeep quiet Open and Learning EnvironmentSafety is an ‘Add on’ Integration into care processes, education, R&D Programmes and Performance AssessmentProfessional and National and International PartnershipsOrganisational Silos Team Work, Local Quality Networks Patient and public involvementCrisis Clear Management systems Agreed work programmes for high impact,
Understanding the nature of error and harm Levels of error and harm
The National Reporting and Learning System (NRLS)• Confidential reporting database• Incidents are reported electronically• 99% come from Local Risk Management Systems• Analysis of data at national level to – identify trends and patterns – provide feedback for local action – inform NPSA work programmes
Care settingCare setting No. %Acute / general hospital 839,974 71.6Mental health service 164,810 14.1Community nursing, medical and therapyservice (incl. community hospital) 116,633 9.9Learning disabilities service 37,663 3.2General practice 4,916 0.4Ambulance service 4,160 0.4Community pharmacy 3,943 0.3Community and general dental service 353 0.0Community optometry / optician service 13 0.0Total 1,172,465 100.0Source: reports to the NRLS up to Dec 2006
Degree of harm to patientsDegree of harm No. %No harm 798,221 68.0Low 295,562 25.2Moderate 64,647 5.5Severe 10,827 0.9Death 4,588 0.4Total 1,173,845 100.0Source: reports to the NRLS up to Dec 2006
NPSA must use all available data sources to inform safety• Administrative data• Clinical incident reports• Medical records• Active surveillance or observation• Surveys - patients, staff• Complaints data
Other datasets. Patient Safety OTHER • Clinical negligence Research ORGANISATIONS • MHRA • Hospital Episodes • GP Databases •complaintsOther confidential PRIORITISATIONreporting systems Surveillance & Monitoring SOLUTIONSNRLS OBSERVATORY EVALUATIONIntelligence NHS Feedback- Healthcare Commission- Expert Groups- Patient/Public- DH/Ministers- Interest Groups etc. R&D Research Public/Patient PATIENTS/ eForm PUBLIC
Ad hoc analysis• Requests from NHS clinicians and risk managers, and relating to current NPSA projects• Use of categorical data supplemented by text searching tool• Examples during one week: – Chest x-ray for work on failure to review x-ray results – Clinical oncology/bone marrow – Learning disabilities choking incidents – Surgical incidents relating to policies and protocols – Maternity beds (elliot and lic types) – Non-medication prescriptions – Home oxygen therapy – Collapsible curtain rails
Systematic review of incidents• Richness of NRLS data in free text descriptions review from clinical perspective adds value• Huge volumes of data – sampling by specialty and incident type• Tools to support robust and consistent review of data supported by guidance and decision tree for follow-up action
Number of incidents W W ro 0 50 100 150 200 250 300 350 ro ng W ng si ro op de ng er pa at tie io n W nt ro C deIn ng ha ng ta co or ils m m es pl is to et si e ng list op pa er tie at N io n nt o si de de ta S ils pe id ci en al tif in ie st d In ru Inc ap ct o io rre c Operating list incidents pr ns op m t ria is te si ng al lo ca tio n O th erto end Oct 06Source: NRLS,
Under-reporting (and bias)• From case note review studies, estimated that LRMS capture 11-17% of patient safety incidents• Does under-reporting matter?• Alternative reporting routes - bias
Access, admission, transfer Incidents from multipleClinical assessment sources in a one hospitalConsent, communication, confid • IncidentsDisruptive aggressive behaviour • ComplaintsDocumentation • ClaimsImplement of care, ongoing • Inquestsmonitoring and reviewInfection control incident • LIRSInfrastructure • Casenotes • PASMedical Device • Datix HSMedication • MHRAPatient abuse • AuditPatient accident • Micro SurvSelf harming behaviourTreatment, procedure Source: Hogan et al
Conclusion• Complaints data is one useful source of data to be used for safety improvement but because people respond to complaints in a variety of ways including being defensive and or not fully disclosing information other multiple sources are needed.• This provides a better more holistic picture of patient safety than any one data set could do so.
“Kevin died. Kevin should not have died. We mournfor Kevin. ….. The tragic outcome in relation toKevin cannot be changed. But can that outcome bea catalyst for change in the reformed health service?
By examining Kevin’s patient journey therecan be real learning and real improvement atall points of patient contact. Perhaps Kevin’sdestiny was to highlight for us the deficienciesand the challenge for us is to learn from hisexperience and to ensure that healthcare issafer for future patients.”(A patient’s mother)