PROGRESS WITH NPSA ALERT IMPLEMENTATION

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1 AGENDA ITEM th September 2013 PROGRESS WITH NPSA ALERT IMPLEMENTATION Executive : Executive Director of Nursing Author: Assistant Director of Patient Safety & Quality Contact Details for further information: Robert Williams or robert.williams@wales.nhs.uk SITUATION The National Patient Safety Agency (NPSA) was a Special Health Authority created in July 2001 to co-ordinate the efforts of the entire country to report, and more importantly to learn from mistakes and problems that affect patient safety. The NPSA plays a key role in bringing patient safety matters to a national level and supports this by releasing alerts and advice on identified patient safety issues, developed in conjunction with professional bodies and patients. It should be noted that in 2012 the NPSA was disbanded, although some of its functions transferred to other host bodies. BACKGROUND The NPSA developed several types of publications to disseminate its advice and solutions to NHS staff. Rapid Response Reports A Rapid Response Report (RRR) is a one page alert providing an urgent warning to healthcare organisations of substantive risks which are new (or not well known) and could be prevented. These require immediate local attention. Patient Safety Alerts A patient safety alert requires prompt action to address high risk safety problems and has a specific timeline for implementation. Safer Practice Notices A safer practice notice advises implementing particular recommendations or solutions which would contribute to improving patient safety. Patient Safety Guidance Patient safety guidance suggests issues or effective techniques that healthcare staff might consider to enhance patient safety. Alert implementation 1 4 September 2013

2 Progress relating to implementation of NPSA publications is a standing item of the Committee work programme and as such the Nurse Director has reported progress to Committee periodically throughout 2010/11 and 2011/12. A flow chart outlining the process for coordinating the implementation of NPSA publications, coordinated through the Patient Safety team, is attached as appendix 1. Arrangements are also in place within Primary Care where alerts are circulated as applicable to independent contractors. ASSESSMENT To date and since 2002, the NPSA has produced more than 70 publications. As at quarter 1 (July 2013) the UHB had implemented all related publications with the exception of those outlined within Appendix 2. Welsh Government has introduced a quarterly monitoring process where Health Boards and Trusts in NHS Wales are required to report compliance progress on a monitoring return. Quarterly compliance improved from 84% to 91% against all alerts last year. In Quarter /14 the UHB is managing a total of 7 outstanding alerts/reports/notices. It should be noted that some of these have been outstanding for some time. There are a variety of reasons why alert implementation has been delayed beyond the recommended target implementation date, these include; unrealistic timeframes for the amount of work involved; the volume of publications launched at the same time has impacted on the ability of the UHB to comply fully within the recommended timescales resource implications. Progress is being made on the outstanding publications and all are currently being worked on, with the majority partially compliant. The attached table (Appendix 2) outlines alerts that are being implemented outside of the recommended target implementation date. The UHB has processes in place for receiving, cascading and implementing NPSA publications. The process for managing Patient Safety Alerts is designed to provide the UHB with assurance regarding the implementation, progress and monitoring of NPSA publications. The UHB continues to make progress with implementation, although a number of long standing alerts remain outstanding. Two of the 7 outstanding require resource allocation to move to compliance. RECOMMENDATION The is asked to; CONSIDER the update provided and the actions proposed to progress implementation. Alert implementation 2 4 September 2013

3 Financial Impact Quality, Safety and Experience Standards for Health Services Risks and Assurance Equality and diversity Whilst there are no financial implications of this report, it should be noted that failure to fully implement NPSA related guidance has the potential to impact financially on the UHB. Implementing NPSA guidance improves quality, safety and the patient experience. Standard 7, Safe and Clinically Effective Care is the key Standard associated with this report. Failure to fully implement NPSA guidance presents a risk to the UHB and raises issues of assurance. There are no equality and diversity implications of this report. Alert implementation 3 4 September 2013

4 APPENDIX 1 IMPLEMENTATION & MONITORING OF NPSA ALERTS PROCESS MODEL 1. NPSA PUBLICATION 2. DISSEMINATION UHB wide (including independent contractors) 3. DESIGNATED LEAD(S) IDENTIFIED 4. BASELINE ASSESSMENT OF COMPLIANCE 5. ACTION PLAN/ GAP ANALYSIS DEVELOPED 6a.PROGRESS REPORTED TO MEDICINES MANAGEMENT GROUP VIA SAFER MEDICATIONS PRACTICE GROUP 6b. PROGRESS REPORTED TO CLINICAL BOARD QUALITY & SAFETY GROUPS 7. FEEDBACK TO QUALITY, SAFETY & EXPERIENCE COMMITTEE (For monitoring purposes) Alert implementation 4 4 September 2013

5 CARDIFF AND VALE UNIVERSITY HEALTH BOARD Appendix 2 NPSA ALERT, REPORT, GUIDANCE COMPLIANCE QUARTER 1, SUBMISSION TO WELSH GOVERNMENT 2013/14 Alert Promoting safer use of injectable medicines Date issued Executive 28/03/2007 Graham Shortland Being Open 19/11/2009 Ruth Senior Operational Status reported at last quarter Current situation including actions being taken with timescales to progress to implementation Darrell Baker The lack of commercially available ready-to-use infusions will preclude full compliance. The UHB has implemented all required actions and will be discussing the position at the next All Wales position as some Health Boards in the same position as the UHB are reporting compliance. Robert Williams There is a requirement for the UHB to update the former Trust s Policy covering Being Open. The approved UHB Incident & Hazard reporting Policy & Procedure, makes strong reference to Being Open within it, as does the revised Putting Things Right / NHS Redress Guidance endorsed and followed by this Health Board. Rapid Response Reports Preventing delay to follow up for patients with glaucoma Date issued Executive 11/06/2009 Chief Operating Officer Senior Operational Alison Davies Status reported at last quarter Current situation including actions being taken with timescales to progress to implementation All staff are now in place, the majority are fully trained. A small number of Allied Health Professional lead clinics working along side consultants have commenced, but this is limited due to space constraints. Foundations are still a problem to support the planned demountable building, but additional funding has been secured. Portacabin is unable due to work commitments to commence building work until late September/early October, but this gives us time to resolve the foundations. Page 1 of 7 Alert implementation 4 September 2013

6 Safer Practice Notices - strongly advises implementing particular recommendations or solutions Safer Patient Identification Date issued Executive 22/11/2005 Ruth Senior Operational Mandy Rayani Status reported at last quarter Current situation including actions being taken with timescales to progress to implementation The Patient Identification Policy has been updated and approved by the Health Board. Practice has been monitored as part of the recent medicines management compliance review and local action (within Clinical Boards) identified. It is planned that the updated policy be profiled in line with the introduction of the electronic wristband solution when procured. Early identification of failure to act on radiological imaging reports Standardising wristbands improves patient safety 05/02/2007 Graham Shortland 03/07/2007 Ruth CD Radiology Mandy Rayani There is an All Wales policy for Critical, Urgent and Unexpected Significant Radiological Findings being developed through the Medical Imaging Sub-Committee. Miscellaneous reports and standards will be adopted across Wales and therefore local policy is not indicated. Radis 2 will be implemented in January 14 which has an electronic handshake of results. Point 3 complete. A detailed progress report on actions being taken in relation to this notice has previously been presented to the former Quality and Safety Committee. Many of this notice s requirements have been implemented, however, key issues relate to the procurement of appropriate hardware to generate patient wristbands at the bed side, or as close to the bed side as possible. An evaluation exercise of available products to support production of wristbands capable of holding all the required patient information took place in February 2012, with preferred option appraisal completed in March The preferred option has been considered by the Nursing and Midwifery Board and is supported. It should be noted however, that the current all-wales contract for wristband associated products is in the process of being reviewed and renegotiated. The existing framework contract has was extended to February 2013, which has allowed the completion of an All-Wales Procurement exercise. Based upon local and all Wales evaluation of possible hardware solutions a preferred model has been identified for use within the UHB. A preferred procurement option is being progressed to purchase the necessary system to support compliance with this alert - a decision on resources to procure the required hardware is pending. Alert implementation 2 4 September 2013

7 Risk to patient safety of not using the NHS Number as the national identifier for all patients 24/06/2009 Ruth Mandy Rayani This safer practice notice encourages increased use of the NHS Number (and its bar-coded equivalent) in/on all correspondence, notes, patient wristbands and patient care systems to support accuracy in identifying patients and linking records. Whilst the NHS number is routinely available within systems, inpatient case notes and patient ID labels, it is not widely used in all health related correspondence. The UHB will continue to raise awareness of the importance of using the NHS Number. There have been no related incidents reported within the UHB where the lack of use of the NHS Number has resulted in harm to a patient. This notice is intrinsically linked to the wristband notice as progressing this requires consideration of what number is to be used on the patient wristband. Alert implementation 3 4 September 2013