The Work of the National Patient

Safety Agency

Joan Russell
Safer Practice Lead-Emergency Care
 Overview
• Patient safety – what, why and how big is the
problem?

• Seven steps to patient safety and the tools to

make a difference

• Ambulance Service Risk Assessment

 Patient Safety – A global issue
18
16
14 USA 3.7%
12 Australia 16.6%
10 England 10.8%
8 Denmark 9%
6 New Zealand 12.9%
4 Canada 7.5%
2 Japan 11%
0
% of acute admissions
Cost of unsafe care each year in the UK…
• 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
 Background

• An organisation with a
memory

• Building a safer NHS for

patients
 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
 Prevented, i.e.
NPSA Definitions not impacted on
patient (previous
NO HARM near miss)
PATIENT SAFETY
Not prevented,
INCIDENT
LOW but resulted in
Any unintended or no harm
unexpected incident(s)
which could have or
did lead to harm for MODERATE
one or more persons
receiving NHS
funded care SEVERE

DEATH
Patient safety e-learning programmes
• 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
Incident Decision Tree
 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
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 and learning system

NHS
NRLS reports

monitor
impact Improved
patient
safety

test & design identification of issues

implement solution prioritisation of solution work
solution
 Step 5
Involve and communicate with patients
and the public
Being Open
Ask about medicines leaflets
SPEAK UP
Involve in investigation
 Step 6 Learn and share safety lessons

• NPSA Root • Over 5000 NHS staff trained in

RCA methodology
Cause Analysis
• E-learning toolkit
Programme
• Guidance
• Aggregated themed RCA
• RCA data capture
• Training for independent
investigations
 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 doesn’t work”

 Ambulance Service Risk Assessment

• To identify existing risks at each stage of the

emergency response process
• To identify possible risk solutions for high risk issues
• Develop a solutions programme of work
 Process
• Identification of risks
• Identification of causes, consequences and controls
• Prioritisation of risks
• Identification of solutions
• Re-evaluation of risk
• Cost/time effectiveness
 Key Themes
• Prioritisation/triage
• Health Care Associated Infection
• Managing Demand
• Transfer of Care
• Equipment Design
 Patient safety observatory and
Patient prioritisation process
Safety
Info
PSO
submissions

NRLS
and
other NPSA work
data programme
sources

NPSA Expert
Board Advisory Filtering of submissions
Panel
Affordances How would you operate these doors?

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

A B C

John R. Grout
Which dial turns on the burner?

Natural Mappings

Stove A

Stove B
 What Can Be Done
to Remove Problems ?

• Design out the problem

• Change the system
• Change practice
• Train the staff
• Involve patients
• Design out the
problem
(design solution)
Clear design
 Case Examples

Cleanyourhands campaign
 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
 1st team of engineers…

Task-‘replace centre console light panel around the throttle

quadrant’

• Throttle levers in full power position

• Take-off warning horn silenced

• Circuit breaker pulled

 Next engineer…
Task-‘trouble shoot a reported engine oil quantity discrepancy’

Requirement of task-undertake an engine run

Guidance-’Pre Power On’ Taxi/Towing Checklist

• Check circuit breakers

• Throttle levers to idle

• Parking break set

 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