Transcript The Patient Safety Challenge in the UK

The Patient Safety Challenge
in the UK
Dr Kevin Cleary
Medical Director
National Patient Safety Agency
The National Patient Safety Agency
• Set up in 2001 to promote patient safety in
the National Health Service in England and
Wales
• Three divisions:
• Patient Safety
• National Clinical Assessment Service
• National Research Ethics Service
Reducing risk to patients
• Work with other health organisations
nationally and internationally
• National reporting system for patient safety
incidents
• Recommendations for healthcare staff and
organisations
National Reporting and
Learning System
• First comprehensive national reporting
system for patient safety incidents
• All NHS organisations connected
• Local to national reporting
• Patient Safety Observatory: using other data
and information sources
Incident data
• Total number of incidents reported:
1,668,427 (up to end of June 2007)
• Between April and June 2007, 242,595
incidents reported
• Most incidents reported electronically via
local risk management systems
(approx 98%)
Patient safety
incidents
reported to
the NPSA,
November
2003 to
June 2007
Reported
incidents,
by type,
April 2006 to
March 2007
Slips, trips and falls
• Patient accident most frequently reported incident
type
• Falls can lead to distress, pain, injury and loss of
independence
• NPSA recommendations include:
• Local analysis of contributing factors
• Creation of falls prevention groups
• Appropriate guidance for staff, particularly in relation to use
of bed rails
Medication safety
• Second most commonly reported incident type
• Each hospital in England and Wales administers
approximately 7,000 medicine doses each day.
• Analysis of 60,000 medication incidents to identify
settings, groups of patients and particular medicines
Medication safety
• Types of medication incidents:
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Wrong dose, strength or frequency
Omitted medicine
Wrong medicine
Wrong patient
Wrong formulation
Wrong route
Medication safety
• Patients at particular risk of medication
incidents:
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Patients who are allergic
Children
Patients moving across care settings
Patients cared for outside of normal processes,
e.g. out-of-hours
Medication safety
• Recommendations on:
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Anticoagulant therapy
Liquid medicines via oral or other enteral routes
Injectable medicines
Epidural injections and infusions
Paediatric intravenous infusions
Medication safety
• Design of medicine packaging
• Estimated that a third of medication errors caused
by confusion over packaging and labelling
instructions
• Design solutions/recommendations to enhance
safety
• Recommendations on dispensing packaging and
dispensing environments to be published late 2007
Care setting
of incident
reports,
April 2006
to March
2007
Care setting of incidents
• Most incidents reported occur in hospitals
(approx 73%)
• Well-established reporting culture in acute sector
• Most healthcare provided in the community
• Need to improve reporting culture in community
settings such as general practice and pharmacy
Ambulance work
• Recommendations to improve safety in
ambulance services:
• Increased consistency in equipment,
consumables and layout
• Standardisation of design of vehicles and
equipment
• Standardised fleet – three core vehicle types
Mental health services
• Analysis of 45,000 reported mental health incidents
• Particular safety issues in this sector:
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Patient accidents
Disruptive, aggressive behaviour
Sexual safety
Self-harm and suicide
Absconding and missing patients
Medication
Reported
degree of
harm to
patients,
April 2006
to March
2007
Safer care of the acutely ill patient
• Analysis of 107 patients whose deaths in
acute hospitals in one year were reported
• Key issues:
• Deterioration not recognised or not acted upon
• Resuscitation after cardiac arrest
Improving care of the deteriorating
patient
• Report due out in November 2007
• Analysis of incidents revealed key themes:
• Lack of observation
• Lack of recognition
• Delay in patient receiving medical attention
Current priorities
• Four major areas of works:
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Anaesthetics care
Neo-natal care
Radiology/radiography involving cancer treatment
Obstetric intra-partum care
• Review of reporting system
• cleanyourhands campaign
• Patient Safety Campaign
Review of reporting system
• Increasing reporting across all settings
• Greater commitment by clinicians and senior
management
• Rapid response process for priority issues,
e.g. reports on:
• Dealing with haemorrhage
• Confusion between drug names
cleanyourhands campaign
• All hospital trusts in England and Wales signed up
to the campaign
• 3rd year of the 4 year campaign to improve hand
hygiene
• Multi-modal approach:
• Alcohol handrub
• Promotional materials to raise awareness
• Tools and resources to aid local implementation
• Currently being piloted in settings outside of
hospitals
Patient Safety Campaign
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Clinical engagement
Management support
National campaign to raise awareness
Focusing on key issues to improve safety
Markers for organisations to measure
success against
Future challenges
• Population of 60 million, complex healthcare
system
• Cultural shift
• Embedding patient safety