Lessons Learnt by the National
    Patient Safety Agency
        14th December 2007
        Dr Helen Glenister
      Deput...
Overview
• Background to NPSA
• National Reporting and Learning System
  in England and Wales
• Using information to make ...
England and Wales
- No. Population: 53,728,800
- No. of Organisations in NHS: 429
- No. of consultations:
  Over 1.5 milli...
NPSA: Background
• An organisation with a
  memory (2000)

• Building a safer NHS
  for patients (2001)

• Safety First: A...
The National Reporting
        Learning System
• All NHS organisations (acute, mental health
  and primary care) are conne...
NRLS
Change of Direction
         • Rapid reporting of
           Patient Safety
           incidents that involve
           s...
Purposes of the National
Reporting and Learning System

• To identify similar incidents and learning to those reported
  t...
Number of patient safety incidents reported by quarter,
            November 2003 to June 2007
Source of Notification to NRLS, by quarter July
                 2006 to June 2007
                                       ...
Care setting of incident reports, July 2006 to
                      June 2007
                                           ...
Reported degree of harm to patients, July 2006 to
                    June 2007
  Number of incidents
  600,000



       ...
Reported Incidents Type
     between July 2006 to June 2007

                         Patient accident                    ...
Using Reporting Systems to
          make change

• Initiatives to make patient care safer
• Initiatives to improve the qu...
Initiatives to Make Care Safer
              • Raise Awareness
              • Issued within two weeks
              • Ide...
Initiatives to Make Care Safer
Solutions: preventing errors: a hierarchy



   Design out the potential for harm

      Make incorrect actions correct


...
Involvement of Patients

• Understand the issues
• Part of the solution
• Produced health service and patient
  Briefing
Using systematic analysis and the ‘observatory’
         approach to learn and respond

Monthly systematic analysis of dea...
Role of Qualitative Data in
      Reporting Systems
• Provides useful additional information for
  learning
• Provides cas...
Initiative to improve the quality and reporting and
               promote a safety culture
             •   Quality Feedb...
Sharing Information for NRLS to
      improve Patient Safety

• Regulator of Health Care (Healthcare
  Commission)
• Commi...
Summary
Lessons from NPSA:
• National Reporting and Learning System is important
  for making change
• Quality of data is ...
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Lessons Learned in the National Patient Safety Agency in UK

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Lessons Learned in the National Patient Safety Agency in UK. Helen Glenister. III International Conference on Patient Safety: "Patients for Patient Safety" (Madrid, Ministry of Health and Consumer Affairs, 2007)

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Lessons Learned in the National Patient Safety Agency in UK

  1. 1. Lessons Learnt by the National Patient Safety Agency 14th December 2007 Dr Helen Glenister Deputy Chief Executive NPSA
  2. 2. Overview • Background to NPSA • National Reporting and Learning System in England and Wales • Using information to make change • Approaches to Solutions Development • Involvement of Patients
  3. 3. England and Wales - No. Population: 53,728,800 - No. of Organisations in NHS: 429 - No. of consultations: Over 1.5 million patients and their families are in contact with NHS services every day - No. of Staff: 1.3 million people employed in NHS
  4. 4. NPSA: Background • An organisation with a memory (2000) • Building a safer NHS for patients (2001) • Safety First: A report for patients, clinicians and healthcare managers (DH 2006)
  5. 5. The National Reporting Learning System • All NHS organisations (acute, mental health and primary care) are connected • Confidential reporting • Incidents are mainly reported electronically and uploaded from Local Risk Management Systems 99% • Direct Reporting
  6. 6. NRLS
  7. 7. Change of Direction • Rapid reporting of Patient Safety incidents that involve serious patient harm and death within 36 hours of the report.
  8. 8. Purposes of the National Reporting and Learning System • To identify similar incidents and learning to those reported through rapid reporting • Follow-up of similar incidents • Identify trends and patterns for priority action in the future • Surveillance of incidents related to risk prevention strategies • Evaluate and inform policy development
  9. 9. Number of patient safety incidents reported by quarter, November 2003 to June 2007
  10. 10. Source of Notification to NRLS, by quarter July 2006 to June 2007 2006 2007 Source of Jul - Sep Oct - Dec Jan - Mar Apr - Jun Notification No. of No. of No. of No. of % % % % Incidents Incidents Incidents Incidents LRMS 200,178 99.0 185,620 98.5 217,752 98.5 239,657 98.8 Eform 1,940 1.0 2,538 1.3 2,685 1.2 2,118 0.9 Community 62 0.0 229 0.1 527 0.2 820 0.3 Pharmacy Total 202,180 100.0 188,387 100.0 220,964 100.0 242,595 100.0 Source: Data is based on date the incident was reported to the NRLS.
  11. 11. Care setting of incident reports, July 2006 to June 2007 Number of incidents 0 100,000 200,000 300,000 400,000 500,000 600,000 Acute / general hospital 530,280 (72.3%0) 109,199 (14.9%) Mental health service Community nursing, medical and therapy 60,984 (8.3%) service (incl. community hospital) Learning disabilities service 25,101 (3.4%) 2,460 (0.3%) Ambulance service Comm. pharmacy 2,449 (0.3%) General practice 2,440 (0.3%) 173 (0.0%) Community and general dental service Community optometry / optician service 3 (0.0%) Source: Data is based on date the reported incident occurred, using data as of 04 July 2007
  12. 12. Reported degree of harm to patients, July 2006 to June 2007 Number of incidents 600,000 488,216 (66.6%) 500,000 400,000 300,000 193,657 (26.4%) 200,000 100,000 42,047 (5.7%) 6,144 (0.8%) 3,006 (0.4%) 0 No harm Low harm Moderate harm Severe harm Death Source: Data is based on date the reported incident occurred, using data as of 04 July 2007. Patient groups and incidents with a missing degree of harm are excluded.
  13. 13. Reported Incidents Type between July 2006 to June 2007 Patient accident 263,915 (36%) Treatment, procedure 66,428 (9.1%) Medication 63,555 (8.7%) Access, admission, transfer, discharge 58,493 (8%) (including missing patient) Infrastructure (including staffing, 42,869 (5.8%) facilities, environment) Documentation (including records, 36,487 (5%) identification) Clinical assessment (including diagnosis, 35,547 (4.8%) scans, tests, assessments) Disruptive, aggressive behaviour 32,547 (4.4%) 28,040 (3.8%) Consent, communication, confidentiality 105,208 (14.4%) All Other incident types
  14. 14. Using Reporting Systems to make change • Initiatives to make patient care safer • Initiatives to improve the quality of reporting and promote a safety culture
  15. 15. Initiatives to Make Care Safer • Raise Awareness • Issued within two weeks • Identifies immediate action • System to track activity • Deadline for completion
  16. 16. Initiatives to Make Care Safer
  17. 17. Solutions: preventing errors: a hierarchy Design out the potential for harm Make incorrect actions correct Make wrong actions more difficult Make it easier to discover errors
  18. 18. Involvement of Patients • Understand the issues • Part of the solution • Produced health service and patient Briefing
  19. 19. Using systematic analysis and the ‘observatory’ approach to learn and respond Monthly systematic analysis of deaths reported to the NRLS in 2005 (n = 1,804) Of these – maybe or was considered directly attributable to a Patient Safety Incident (n = 576) Reveals 3 main themes: 1. Diagnostic error (n = 86) 2. Deterioration not recognised or not acted upon (n = 66) 3. Resuscitation (n = 59)
  20. 20. Role of Qualitative Data in Reporting Systems • Provides useful additional information for learning • Provides case studies to illustrate points which front-line clinicians relate to • Brings incidents and learning alive
  21. 21. Initiative to improve the quality and reporting and promote a safety culture • Quality Feedback Reports to Trusts
  22. 22. Sharing Information for NRLS to improve Patient Safety • Regulator of Health Care (Healthcare Commission) • Commissioners of Health Care • Performance Management of Health Care
  23. 23. Summary Lessons from NPSA: • National Reporting and Learning System is important for making change • Quality of data is a challenge • Need new approaches to Solution Development • Involvement of Patients – important element to raise awareness to be part of the solutions
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