7 Steps Patient Safety

Seven steps to patient safety: A route
map to delivering a safer health care

system in England & Wales
Susan Williams
Joint Chief Executive
National Patient Safety Agency
Overview
Patient safety what, why and how big is
the problem in the UK
Role of National Patient Safety Agency
Seven steps to patient safety and the tools
to make a difference
Patient Safety A global issue

18
16
14
Australia 16.6%
England 10.8%
Denmark 9%
New Zealand 12.9%
Canada 7.5%
Japan 11%
12
10
8
6
4
2
0
% of acute admissions
Patient Safety A National Issue

10% of admissions = 900,000 patients affected
around 1 billion/year in extra hospital stay costs
average 8.5 extra bed days
400 people die or are seriously injured in incidents
involving medical devices
450 million clinical negligence settlements
over 1 billion spent on hospital associated
infections
29 million direct costs related to staff suspension
Patient Safety A Local Issue

A typical acute hospital with 500 beds
No. of Admissions
No. of PSIs
Moderate to severe
Preventable
No. of extra bed days
Cost
Number of claims p.a
Settlement payments
30,000
3,200
1,100
1,500
27,400
7.4m
20
1.2m
Sources: DOH, HES and Activity States 2002, NHS Negligence claims CNST, Vincent et al.
2001
UK Context
Organisation with a
Memory 2000
Building a Safer NHS 2001
Bristol Enquiry July 2001
Nottingham January
2001
What is the
National Patient Safety Agency?
advise Ministers
promote R&D
track progress
develop NHS-wide solutions
assimilate information from others
capture and analyse incidents
Purpose of the NPSA

Help the NHS to:
learn from things that go wrong
develop and implement solutions to problems
improve patient safety in frontline services
Focus on:
systems not individuals

learning not judgement
fairness not blame
openness not secrecy
all care settings not just acute care
Seven Steps
1. Build a safety culture that
is open and fair
2. Lead and support your
staff in patient safety
3. Integrate your risk
management activity
4. Promote reporting
5. Involve patients and the
public
6. Learn and share safety
lessons
7. Implement solutions to
prevent harm
Step 1 - Build a safety culture that is open

and fair
Safety is considered in everything you do
There is a balanced approach when things
go wrong - you ask why and not who
Constant vigilance
Openness with patients fair for all staff
Incident Decision Tree
Balancing individual v- system error

Individual approach
error prone people individuals are careless, at
fault, reckless
Systems approach
error prone situations poor organisational design
sets people up to fail
Find someone to blame

punish, shame and train
Focus on multiple
contributing factors not
just actions of individual
Fix individual = improve

safety
Redesign the process =

improve safety
the perfection myth

if we try hard
enough we will not
make any errors
the punishment myth
if we punish people
when they make
errors they will
make fewer of them
Application of human factors

Relying too much on human memory
Solution: decision aids, electronic alerts, checklists
Poor communication between members of the team

Solution: team briefing and de-briefing
Vulnerable handover points across care boundaries

Solution: clearly identified roles and responsibilities
Wide variety of equipment in use

Solution: standardisation where relevant
Inadequate orientation / induction / rehearsal

Solution: rehearsal simulation training, induction training
Step 2
Leadership and support
Leadership advised to:
Undertake executive walkabouts
Develop team safety briefing and
debriefing
Appoint patient safety clinical champions
Undertake safety culture and team culture
assessments
Levels of maturity with respect to a safety

culture
Why waste
our time on
safety?
We do
something
when we
have an
incident
Pathological
Reactive
We have
systems in
place to
manage all
like risks
Calculative
We are
always on
the alert for
risks that
might
emerge
Proactive
Risk
management
is an integral
part of
everything
that we do
Generative
Commitment to Q
Priority to PS
Causes
Investigation
Learning
Communication
Personnel
Education
Team working
Patient safety e-learning

programmes
Step 3 - Integrated risk management
all risk management functions and information:

patient safety,
health and safety,
complaints,
clinical litigation,
employment litigation,
financial and environmental risk
training, management, analysis, assessment and

investigations
processes and decisions about risks into business
and strategic plans
Step 4
Promote reporting
National reporting and learning system (NRLS)
Reporting via:
local risk management systems
E-form on NHS net
E-form on www
Anonymous (names of patients and staff)

Confidential (names of organisations)
National Reporting & Learning System

electronic system to enable NHS organisations
and staff to report patient safety incidents to a
national database in order to:
analyse and report on data
encourage improved reporting
help the NHS learn from errors and system
failures
build a more open and fair culture in the NHS
NPSA Definitions
NO HARM
PATIENT SAFETY
INCIDENT
Any unintended or
unexpected incident(s)
which could have or
did lead to harm for
one or more persons
receiving NHS
funded care
LOW
MODERATE
SEVERE
DEATH
Prevented, i.e.
not impacted on
patient (previous
near miss)
Not prevented,
but resulted in
no harm
Design of the Reporting System
anonymous (patients and staff)

confidential (NHS organisations)
voluntary
hypothesis generating and learning
complement not replace local reporting
build on local risk management systems
streamline impact at frontline
patient and public reporting (over time)
PRIORITISATION
Research by NPSA
-With others
-Criteria/methods
Patient Safety Research
-(rapid response)
-Lit review
-Topic selection
OTHER ORGANISATIONS
CHAI, DoH etc
NRLS
Other bodies & Their views
Surveillance
&
Monitoring
Public/Patient e-form
OBSERVATORY
Other confidential reporting
SHAs
NICE
EVALUATION
DoH/Ministers
CMO
CPPIH
systems
VOs/Charities
R&D
Other dataset relevant to
patient safety
NHS Feedback Sources of

& Bounceback Intelligence/Knowledge
e.g. MRHA
NCAA
-CSAs, PSMs & Expert Groups

-PEPI & Patient/Public Views
PATIENTS/
CHAI Reviews
-Individual Patients
PUBLIC
HES
-Interest Groups etc.
RCGP Database
NHS Direct
Results
Hospital system (DA)
system(DB)
68
CICU consultants
44
99
Both
Ricci, Goldman, de Leval, Cohen, Devaney and Carthey 2004
Local Risk
Management
System
Service
eForm
Service
eForm
Public
eForm
WWW
NHS Net
Encrypted
traffic
Feedback
national
trends
Feed
Back Web
Pages
National Reporting and Learning System

Analysis
Secure
Database
Anonymisation
Cleansed
Database
National reporting and learning system

NHS
reports
NRLS
monitor
impact
test &
implement
solution
Improved
patient
safety
design
solution
identification of issues
prioritisation of solution work
eForm Look and Feel
SAS 3D Bar Chart
SAS Control Chart
Autonomy Cluster Map

dining room, door, tv
126 documents
Found on floor beside bed.
Found on floor between bed and commode.
Found on floor by sluice.
Patient was attempting to get out of bed to commode when his feet slipped
and
Patient walking with walking aid in dining room - loud crash. Patient fallen to
ground
While walking from one dining area to the next, patient tripped over door
threshold resulting
Patient attempting to throw tv, alarm activated, several staff attended and
intervened, there were other
While attempting to get up and stand at the side of bed patient slipped onto
Patient sound on floor, says he slipped of bed.
Patient had been on commode he said he stood up without asking for
assistance and
cord Ph, baby, paed
60 documents
Patient readmitted to CHDU following transfer to ward area from [Ward
name].This patient was readmitted
Baby born NVD - Cord ph 6.94. Apgars 7,10. Paed SHO informed - to observe
Low cord Ph's
Low cord ph's 7.185 + 7.177
NVD with normal CTG's during labour - clear liquor. Cord pH 7.052
Baby born and did not establish regular respirations and was put on the
resuscitaire and
Uneventful labour. Caesarean delivery with cord round neck. Slipped over at
the time cord Ph
NVD at 36/40. Paed called to review baby who was grunting advised to
observe. Baby
Mother had IOL for obstetric cholestasis. ARM - meconium stained liquor. Baby
Ph 7.06, 7.132
Lucien Leape
To understand an adverse event and
prevent future problems requires analysis.

You have to examine, investigate and talk
to people.
Step 5
Involve and communicate with patients
and the public
Being open principles
Apologise and explain
Find out the causes
Offer support in coping with the consequences
Advise about ongoing treatment required
Involve patient and carer in the investigation and
the recommendations for change
NPSA Being Open Toolkit

Policy
What to say, who should say it and when
Video
Case studies to demonstrate communicating bad news
Training programme
Groups of 16 using actors to role play scenarios
E-learning
To be available on the www 2005
Step 6 Learn and share safety lessons

Root Cause
Analysis
A structured, robust
approach to incident
investigation which looks
beyond the immediate
actions and assumed
causes and identifies the
contributory factors, latent
conditions and root causes
which lead to an incident
occurring.
NPSA RCA programme

Over 5000 NHS staff trained in RCA
methodology
E-learning toolkit
Guidance
Aggregated themed RCA
RCA data capture
Training for independent investigations
Individual factors
Step 7
Solutions to Prevent Harm
Address root causes
Make designs of equipment, systems, processes,
more intuitive
Make wrong actions more difficult
Make incorrect actions correct
Make it easier to discover error
Telling people to be more careful doesnt work
Affordances
How would you operate these doors?
Push or pull? left side or right? How did you know?
John R. Grout
What Can Be Done

to Remove Problems ?
Design out the problem

Change the system
Change practice
Train the staff
Involve patients
Forms of NPSA advice
A patient safety alert requires prompt action

to address high risk safety problems
A safer practice notice strongly advises

implementing particular recommendations or
solutions
Patient safety information suggests issues or

effective techniques that healthcare staff
might consider to enhance safety
NPSA Patient Safety

Alert 1:
Preventing
Accidental Overdose
with Intravenous
Potassium
Summary of Safety Controls for Potassium Chloride Solutions

Before and After Safety Alert
Positive Responses %
100%
87%
69%
75%
Before Alert
2002 (n=172)
2003 (n=154)
50%
25%
25%
0%
Time of data sample
Case Examples
Cleanyourhands campaign
Hand hygiene and compliance according to risk category and

observation period
(the size of the symbol is proportional to the number of opportunities observed)
120%
100%
Compliance
80%
60%
40%
20%
0%
May-03
Jun-03
Jul-03
Aug-03
Sep-03
Oct-03
Nov-03
Dec-03
Observation Month
Low Risk
Medium Risk
High Risk
Linear (Low Risk)
Linear (Medium Risk)
Linear (High Risk)
Jan-04
Patient safety incidents with oral

methotrexate 1993-2002
70
60
50
40
T otal
Harm
Death
30
20
10
0
prescribing
the wrong
frequency
lack of
monitoring
dispensing
error
other causes
137 cases, 25 deaths
Improving Labelling and Packaging

A partnership with
UK manufacturers
of Methotrexate to
develop novel
packaging designs
Alerts in clinical IT systems

A project to adapt IT
systems in GP
surgeries and
community
pharmacies to
incorporate flagging
mechanisms to
provide alerts
Improving Infusion Device Safety
Average per hospital

31 different types
1065 pumps in stock
65% lying about under utilised
Potential cost savings by

standardizing equipment and
creating a central store:
161,667 per hospital
33.7 million across NHS
To err is human
To cover up is unforgivable
To fail to learn is inexcusable
Sir Liam Donaldson
Chief Medical Officer
England
Thank you for listening

Any questions?
Need help contact;
www.npsa.nhs.uk

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Seven steps to patient safety: A route

map to delivering a safer health care

Patient Safety A global issue

Patient Safety A National Issue

Patient Safety A Local Issue

Purpose of the NPSA

systems not individuals

Step 1 - Build a safety culture that is open

Incident Decision Tree

Balancing individual v- system error

Find someone to blame

Fix individual = improve

Redesign the process =

the perfection myth

Application of human factors

Poor communication between members of the team

Vulnerable handover points across care boundaries

Wide variety of equipment in use

Inadequate orientation / induction / rehearsal

Levels of maturity with respect to a safety

Patient safety e-learning

Step 3 - Integrated risk management

all risk management functions and information:

training, management, analysis, assessment and

Anonymous (names of patients and staff)

National Reporting & Learning System

Design of the Reporting System

anonymous (patients and staff)

Patient Safety Research

Other confidential reporting

NHS Feedback Sources of

-CSAs, PSMs & Expert Groups

-Interest Groups etc.

Ricci, Goldman, de Leval, Cohen, Devaney and Carthey 2004

National Reporting and Learning System

National reporting and learning system

eForm Look and Feel

SAS 3D Bar Chart

SAS Control Chart

Autonomy Cluster Map

To understand an adverse event and

prevent future problems requires analysis.

NPSA Being Open Toolkit

Step 6 Learn and share safety lessons

NPSA RCA programme

How would you operate these doors?

Push or pull? left side or right? How did you know?

What Can Be Done

Design out the problem

Forms of NPSA advice

A patient safety alert requires prompt action

A safer practice notice strongly advises

Patient safety information suggests issues or

NPSA Patient Safety

Summary of Safety Controls for Potassium Chloride Solutions

Time of data sample

Hand hygiene and compliance according to risk category and

Linear (Low Risk)

Linear (Medium Risk)