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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: • • • • • • Wrong dose, strength or frequency Omitted medicine Wrong medicine Wrong patient Wrong formulation Wrong route Medication safety • Patients at particular risk of medication incidents: • • • • 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: • • • • • 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: • • • • • • 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: • • • • 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 • • • • • 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