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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