Transcript The London Cluster

Patient Safety
Tony Newman-Sanders
National Clinical Advisor
NHS CFH London Cluster
Structure and Documentation
• NPSA only involved once Trusts
connected to spine.
• Best practice documentation
• Most issues local /Trust/entity
responsibility.
• Role of LSPs
– Safety documentation patchy
Old issues and New opportunities
• Old issues
– IRMER
– Incorrect patient ID or Study ID
– Notification and action on reports
• New opportunities
– Improved access to reports, PDA bedside telephony
etc
– Integrating other data eg text books, drug data
– CAD,
– Comprehensive error review, double reporting etc
Ionising Radiation
• Several RIS-PACS issues identified at BLT
– Nuclear Medicine
– Vetting, approving, justifying
• Report data
• Implications of rapid roll out of CR
– Specific equipment issues
– Radiographer behaviour
Patient ID
• Intrinsically much safer than film
• Significant possibilities for error
• Unique Patient ID
– NHS number
– PAS number plus prefix
– RIS (PACS) generated number plus prefix
• What is easily accessible to clinicians?
• Webbrowser design.
Notification and acting on results
• Significant proportion of cases of serious
harm or death identified by NPSA
• NCRP tasked with identifying where the
solutions lie
– PAS
– RIS
– PACS
Interdependencies
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Structure of archiving
Connectivity within cluster
Legal liability issues
Short term IG vs strategic robustness.
Responsibility and reporting structure
New opportunities
• Improved access to reports, PDA bedside
telephony etc
• Integrating other data eg text books, drug
data ????NICE
• CAD,
• Comprehensive error review, double
reporting etc
• Any others?