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NPSA’s role in complaints
Failures in standards of care     DYSFUNCTIONAL       POOR        SERVICE      PRACTITIONER                     PERFORMANC...
Healthcare                   ResponsibilitiesCommission                                                National Clinical  ...
Purpose of the NPSASpecial health authority with mandate to:   – implement a national reporting system     for patient saf...
Understanding the context of        complaints
Vision for NPSA Creating a Safer NHSCurrent Position        Future PositionBlame the reporter      Praise the reporterKeep...
Understanding the nature of error           and harm         Levels of error and harm
The National Reporting and Learning              System (NRLS)•   Confidential reporting database•   Incidents are reporte...
Care settingCare setting                                 No.           %Acute / general hospital                      839,...
Degree of harm to patientsDegree of harm                           No.             %No harm                               ...
Seeing the whole picture
NPSA must use all available data          sources to inform safety•   Administrative data•   Clinical incident reports•   ...
Other datasets.               Patient Safety             OTHER • Clinical negligence          Research                  OR...
Learning from the NRLS and the             PSO
Routine and thematic reports• Thematic reports• Bulletin• Trust feedback reports
Patient Safety  Observatory reports
Patient Safety Bulletin
Routine infusion of fluids• Single report of fatal incident  following inappropriately  prescribed fluids• Few reports rel...
Comparative feedback reports
Ad hoc analysis•   Requests from NHS clinicians and risk managers, and relating    to current NPSA projects•   Use of cate...
Systematic review of incidents• Richness of NRLS data in free text  descriptions review from clinical perspective  adds va...
Number of incidents                      W               W         ro                                           0         ...
Under-reporting (and bias)• From case note review studies, estimated  that LRMS capture 11-17% of patient safety  incident...
Access, admission, transfer        Incidents from multipleClinical assessment               sources in a one hospitalConse...
Conclusion• Complaints data is one useful source of data to be  used for safety improvement but because people  respond to...
“Kevin died. Kevin should not have died. We mournfor Kevin. ….. The tragic outcome in relation toKevin cannot be changed. ...
By examining Kevin’s patient journey therecan be real learning and real improvement atall points of patient contact. Perha...
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NPSA’s role in complaints

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  • 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
  • Transcript of "NPSA’s role in complaints"

    1. 1. NPSA’s role in complaints
    2. 2. Failures in standards of care DYSFUNCTIONAL POOR SERVICE PRACTITIONER PERFORMANCE SYSTEM WEAKNESSES SUBOPTIMAL SERVICE DELIVERY
    3. 3. Healthcare ResponsibilitiesCommission National Clinical Assessment Service DYSFUNCTIONAL POOR SERVICE PRACTITIONER PERFORMANCE PATTERNS & SYSTEMS SUBOPTIMAL SERVICE DELIVERYNational PatientSafety Agency Trust Boards and Strategic Health Authorities
    4. 4. 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
    5. 5. Understanding the context of complaints
    6. 6. 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,
    7. 7. Understanding the nature of error and harm Levels of error and harm
    8. 8. 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
    9. 9. 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
    10. 10. 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
    11. 11. Seeing the whole picture
    12. 12. 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
    13. 13. 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
    14. 14. Learning from the NRLS and the PSO
    15. 15. Routine and thematic reports• Thematic reports• Bulletin• Trust feedback reports
    16. 16. Patient Safety Observatory reports
    17. 17. Patient Safety Bulletin
    18. 18. Routine infusion of fluids• Single report of fatal incident following inappropriately prescribed fluids• Few reports related to this – not a well recognised risk?• Recommendations
    19. 19. Comparative feedback reports
    20. 20. 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
    21. 21. 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
    22. 22. 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,
    23. 23. 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
    24. 24. 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
    25. 25. 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.
    26. 26. “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?
    27. 27. 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)
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