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Patient safety thinking differently
- 1. Patient safety: thinking differently Exploring the challenges in patient safety improvement from national, local and personal perspectives Frances Healey, RGN, RMN, PhD Head of Patient Safety Insight, NHS England 4 December 2014
- 2. Patient Safety ’Fellows’ Patient Safety Collaboratives A system devoted to continual learning and improvement NRLS NaPSAS Data Transparency Retrospective case note review Vulnerable groups Vulnerable points of care Key types of harm and reduce harm by 50% SAFE team NHSEngland’sIntegratedPatient SafetyStrategyfortheNHS www.england.nhs.uk
- 3. Around 12,000,000 incidents have been reported. Approximately 4,000 incidents are reported to the NRLS per day Around 94% of incidents cause low or no harm 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 Oct - Dec 2003 Apr - Jun 2004 Oct - Dec 2004 Apr - Jun 2005 Oct - Dec 2005 Apr - Jun 2006 Oct - Dec 2006 Apr - Jun 2007 Oct - Dec 2007 Apr - Jun 2008 Oct - Dec 2008 Apr - Jun 2009 Oct - Dec 2009 Apr - Jun 2010 Oct - Dec 2010 Apr - Jun 2011 Oct - Dec 2011 Incidents submitted
- 4. Scale of the problem: reported incidents • Each report an opportunity to learn: 68% no harm & 25% low harm • But each report also represents actual or potential distress or harm to patients and concern from staff NRLS Quarterly Data workbooks April 2012 – March 2013 England data: 1,353,430 incidents in total Other Patient abuse (by third party/staff) Infection Control Incident Medical device / equipment Disruptive, aggressive behaviour Self-harming behaviour Consent, communication, confidentiality Clinical assessment & diagnosis Infrastructure Documentation Access, admission, transfer, discharge Medication Treatment, procedure Implementation of care Patient accident 0 50,000 100,000 150,000 200,000 250,000 300,000 350,000
- 5. “But we are interested in future harm, not past harm” • We need to embrace the challenges and opportunities set out by the Health Foundation’s The measurement and monitoring of patient safety • But past harm matters because: – The NHS today is not so very different from the NHS earlier this year; our processes, pressures, patient groups, staff, buildings, equipment, and training will not have radically changed since the period these data are drawn from – Therefore the patterns of human error, and poorly designed systems that fail to prevent harm reaching the patient, are likely to recur until we make improvements
- 6. Don’t count incident reports, read them….
- 7. Patient Safety ’Fellows’ Patient Safety Collaboratives A system devoted to continual learning and improvement NRLS NaPSAS Data Transparency Retrospective case note review Vulnerable groups Vulnerable points of care Key types of harm and reduce harm by 50% SAFE team NHSEngland’sIntegratedPatient SafetyStrategyfortheNHS www.england.nhs.uk
- 8. National Patient Safety Alerting System (NaPSAS) www.england.nhs.uk • A new system launched in January 2014 for alerting the NHS to emerging patient safety risks • Builds on the best elements of the former National Patient Safety Agency (NPSA) system • A three-stage alerting system based on other high risk industries such as aviation
- 9. NRLS death & severe Potential new risks received from: Coroners NHS staff Professional bodies Clinical audit/mortality Public/patients Other national organisations NO ACTION - risk not significant - action already underway - action not feasible Resolution: FOR ACTION BY OTHERS Information handed over NaPSAS ALERT 1. Warning 2. Resource 3. Directive FOR OTHER ACTION e.g. social movements, collaboratives, education, etc. Triage: Discussion Information gathering Detailed insight from expert groups Decision
- 10. Targeted audience‘Story’ of trigger incident Number and nature of similar errors
- 11. Works with differing levels of organisational maturity A. Why waste our time on safety? B. We do something when we have an incident C. We have systems in place to manage all identified risks D. We are always on the alert for risks that might emerge E. Risk management is an integral part of everything that we do PATHOLOGICAL REACTIVE BUREAUCRATIC PROACTIVE GENERATIVE The Manchester Patient Safety Assessment Framework
- 12. Patient Safety ’Fellows’ Patient Safety Collaboratives A system devoted to continual learning and improvement NRLS NaPSAS Data Transparency Retrospective case note review Vulnerable groups Vulnerable points of care Key types of harm and reduce harm by 50% SAFE team NHSEngland’sIntegratedPatient SafetyStrategyfortheNHS www.england.nhs.uk
- 13. Scale of the problem: death & severe harm 19% 17% 14% 8% 6% 6% 6% 5% 9% Suicide/severe self harm Fall (hip #/sub-dural) Pressure ulcer grade 4 Treatment error or delay Obstetric-specific incident Operation/procedure related Clinical diagnostic error/delay Missed deterioration Medication incident Healthcare associated infection Pulmonary embolus Test results not acted on Transfer or discharge incident Other/unclear NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data: 8,018 incidents Over 8,000 reported fatal or severe harm incidents each year
- 14. Scale of the problem: other sources • Around 4,400 people commit suicide each year; 27% are known to mental health services; most are known to GPs • 4,849 deaths related to VTE within 120 days of hospital admission (for reasons other than VTE) each year • 9,500 patients with grade 2/3/4 pressure ulcers on each monthly survey • Around 3,000 hip fractures from falls in hospitals each year identified by the National Hip Fracture database NCISH 2014 report - HSCIC NHS OF Aug 2014 - Safety Thermometer Sept 2014 – NHFD 2014 report Suicides - England 2002-2012 The largest areas of harm remain large because they are ‘wicked problems’ which need complex, wide-ranging and sustained improvement efforts
- 16. Patient Safety ’Fellows’ Patient Safety Collaboratives A system devoted to continual learning and improvement NRLS NaPSAS Data Transparency Retrospective case note review Vulnerable groups Vulnerable points of care Key types of harm and reduce harm by 50% SAFE team NHSEngland’sIntegratedPatient SafetyStrategyfortheNHS www.england.nhs.uk
- 17. 17 • 5% of deaths potentially avoidable Median age 80 years Main problem types: • Clinical monitoring (in the broad sense) 31% • Diagnostic error & delay 30% • Fluids and medication 21% • Average 4 problems in healthcare per avoidable death
- 18. Patient Safety Incident Not classic Swiss cheese “bull’s eye”
- 19. Patient Cumulative effect of more minor harms “death by a thousand cuts”
- 20. Are you confident potentially avoidable deaths discussed in mortality meetings are reported as incidents and known to your Board?
- 21. Patient Safety ’Fellows’ Patient Safety Collaboratives A system devoted to continual learning and improvement NRLS NaPSAS Data Transparency Retrospective case note review Vulnerable groups Vulnerable points of care Key types of harm and reduce harm by 50% SAFE team NHSEngland’sIntegratedPatient SafetyStrategyfortheNHS www.england.nhs.uk
- 22. Acute care settings: patient age within death and severe harm incidents 22 21% 27% 17% 9% 6% 7% 6% 3% 4% Over 85 years 76 to 85 years 66 to 75 years 56 to 65 years 46 to 55 years 36 to 45 years 26 to 35 years 18 to 25 years Under 17 years NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data
- 24. Patient Safety ’Fellows’ Patient Safety Collaboratives A system devoted to continual learning and improvement NRLS NaPSAS Data Transparency Retrospective case note review Vulnerable groups Vulnerable points of care Key types of harm and reduce harm by 50% SAFE team NHSEngland’sIntegratedPatient SafetyStrategyfortheNHS www.england.nhs.uk
- 25. 25
- 26. 26
- 28. And the response to NHS Choices publication?
- 29. 29
- 31. 31www.england.nhs.uk “The results at that stage showed a slight numerical advantage for those who had been treated at home. It was of course completely insignificant statistically. “I rather wickedly compiled two reports, one reversing the numbers of deaths on the two sides of the trial. As we were going into committee, in the anteroom, I showed some cardiologists the results……..
- 32. 32 “……they were vociferous in their abuse: `Archie’, they said, `we always thought you were unethical. You must stop the trial at once…’ “I let them have their say for some time and then apologised and gave them the true results, challenging them to say, as vehemently, that coronary care units should be stopped immediately. “There was dead silence and I felt rather sick because they were, after all, my medical colleagues.” Professor Archibald Cochrane & Max Blythe One Man's Medicine (1989) p.211
- 33. 33 “cognitive dissonance” http://britishgeriatricssociety. wordpress.com/2013/05/16/al l-down-to-numbers/ “data used for reassurance”
- 34. Patient Safety ’Fellows’ Patient Safety Collaboratives A system devoted to continual learning and improvement NRLS NaPSAS Data Transparency Retrospective case note review Vulnerable groups Vulnerable points of care Key types of harm and reduce harm by 50% SAFE team NHSEngland’sIntegratedPatient SafetyStrategyfortheNHS www.england.nhs.uk
- 36. http://m.qualitysafety.bmj.com/content/23/11/880.full "The consistent delivery of well-executed safe care under typically difficult circumstances tends to go unrecognised"