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Sharing to Sustain – making PCT
land a safer place!
Peter Mansell & Maureen Baker NPSA
March 9th 2004
Three questions
• What information is going to be most useful to
inform safer choices?
• How do we best involve users to improve patient
safety?
• How can the NPSA complement the work of
PCTs?
Context 4 - GP adverse events frequency
• medication
15%
- wrong drug
- wrong dose
- known allergy
• misdiagnosis
50%
• minor surgery
5%
7%
• referral
• delayed diagnosis:- malignancy, orthopaedics, infection
Sources: MDU Claims settled 1990-2000
Sources of information
What are some of the ways of engaging
patients and the public about a safer
choices?
Complaints
RCAs
Patient Surveys
Patient Forums NRLS Thematic reviews
Involving users for making things safer
•
Providing information on safety performance of
healthcare organisations and services
– How do we guard against unintended outcomes?
•
Jointly developing national patient safety
goals/standards
– Can we assure a core level of safety?
•
Publishing data
– What will be meaningful and not unduly erode trust?
•
Working with patients on solutions
– Decisions about when and how we involve people will
always be difficult
Motivation to act
•
•
•
Variation in quality exists and I may not get the
best quality
Failure to act will have a negative effect on
health
The harm that will result from failure to act:
– is greater than any risk which is perceived to be
associated with the action;
– is greater than the burden of time and effort involved in
taking action
OPM/The Nuffield Trust Involving People in Public Disclosure of Clinical Data
Which is the safer organisation?
Reported incidents 200
per annum
180
160
140
120
100
80
60
40
20
0
Organisation Organisation Organisation Organisation
A
B
C
D
Supporting Choice
•
7 steps to patient safety – developing tools to
help you:
1.
2.
3.
4.
5.
6.
7.
Build safer cultures
Lead and support your staff
Integrate your risk management activity
Promote reporting
Involve patients and the public
Learn and share safety lessons
Implement solutions
Discussion and Questions