A Safer Place for Patients: Learning to improve patient safety

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1 departmet of health A Safer Place for Patiets: Learig to improve patiet safety REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 456 Sessio November 2005

2 The Natioal Audit Office scrutiises public spedig o behalf of Parliamet. The Comptroller ad Auditor Geeral, Sir Joh Bour, is a Officer of the House of Commos. He is the head of the Natioal Audit Office, which employs some 800 staff. He, ad the Natioal Audit Office, are totally idepedet of Govermet. He certifies the accouts of all Govermet departmets ad a wide rage of other public sector bodies; ad he has statutory authority to report to Parliamet o the ecoomy, efficiecy ad effectiveess with which departmets ad other bodies have used their resources. Our work saves the taxpayer millios of pouds every year. At least 8 for every 1 spet ruig the Office.

3 A Safer Place for Patiets: Learig to improve patiet safety LONDON: The Statioery Office Ordered by the House of Commos to be prited o 31 October 2005 REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 456 Sessio November 2005

4 cotets summary 1 This report has bee prepared uder Sectio 6 of the Natioal Audit Act 1983 for presetatio to the House of Commos i accordace with Sectio 9 of the Act. Joh Bour Comptroller ad Auditor Geeral Natioal Audit Office 31 October 2005 The Natioal Audit Office study team cosisted of: Aliso Terry, Catherie Mottram, Jeff Roud, Ella Firma, Joh Step, Soia Ashby ad Jo Allard, uder the directio of Kare Taylor This report ca be foud o the Natioal Audit Office web site at For further iformatio about the Natioal Audit Office please cotact: Natioal Audit Office Press Office Buckigham Palace Road Victoria Lodo SW1W 9SP Tel: equiries@ao.gsi.gov.uk Natioal Audit Office 2005 Part 1 The safety culture withi NHS trusts 12 is ow more ope ad fair Progress has bee made both locally ad 13 atioally i ecouragig a ope ad fair culture Most trusts have established a clear ad strog 16 focus o patiet safety Most trusts have improved their patiet safety 18 eviromet i respose to risk maagemet requiremets Part 2 Local reportig has improved but there 22 have bee delays i establishig a effective atioal system All trusts have orgaisatio-wide patiet safety 23 reportig systems I 2000 A orgaisatio with a memory idetified 32 weakesses i the plethora of icidet reportig systems used i the NHS A orgaisatio with a memory proposed a sigle 34 focal poit for iformatio o patiet safety icidets but this has ot bee achieved

5 Part 3 Systems for aalysig ad sharig 40 lessos leared are i place but are largely uder-used Good foudatios have bee laid for improvig 41 the quality ad relevace of local icidet ivestigatios Trusts have idetified ad implemeted lessos 43 from icidets but few kew of the cost-effectiveess of the itervetios Trust-wide applicatio of lessos ad embeddig 48 of learig is patchy Natioally the focus has bee o processes ad 50 systems rather tha orgaisatioal learig Appedices 1 Refereces to patiet safety i previous 57 Natioal Audit Office ad Committee of Public Accouts reports 2 Methodology 60 3 Other Idustries 65 4 Iteratioal comparisos of orgaisatioal 67 learig for patiet safety 5 Itegratig trusts reportig systems with the 71 Natioal Reportig ad Learig System 6 Outputs from the Natioal Patiet 73 Safety Agecy 7 Measurig Risk Maagemet ad Performace 76 Glossary 80 Bibliography 85 Photographs courtesy of Justie Desmod photography

6 summary summary

7 summary 1 Every day over oe millio people are treated successfully by Natioal Health Service (NHS) acute, ambulace ad metal health trusts. However, healthcare relies o a rage of complex iteractios of people, skills, techologies ad drugs, ad sometimes thigs do go wrog. For most coutries, patiet safety is ow the key issue i healthcare quality ad risk maagemet. The Departmet of Health (the Departmet) estimates that oe i te patiets admitted to NHS hospitals will be uitetioally harmed, a rate similar to other developed coutries. Aroud 50 per cet of these patiet safety icidets a could have bee avoided, if oly lessos from previous icidets had bee leared. Figure 1 details some of the key facts. Patiet safety icidet: ay uiteded or uexpected evet that lead to death, disability, ijury, disease or sufferig for oe or more patiets Near miss: ay situatio that could have resulted i a accidet, ijury or illess for a patiet, but did ot, due to chace or timely itervetio by aother 1 Key facts ad best estimates about the extet ad impact of patiet safety icidets A aalysis of 256 (96 per cet) NHS acute, ambulace ad metal health trusts resposes to our mai survey showed that i trusts recorded some 885,832 icidets ad ear misses. Our follow up survey foud that for there were aroud 974,000 reported icidets ad ear misses. Few trusts icluded hospital acquired ifectios which may icrease this by aroud 300,000 icidets (aroud 30 per cet of which may have bee prevetable). The most commo icidets reported were: patiet ijury (due to falls), followed by medicatio errors, equipmet related icidets, record documetatio error ad commuicatio failure. Whilst reports of ear misses have also icreased, far fewer are reported tha research suggests should be the case. Patiet safety icidets cost the NHS a estimated 2 billio a year i extra bed days, i additio hospital acquired ifectios add a further 1 billio to these costs 1. The cost of settled cliical egligece claims i was 423 millio ad provisios for outstadig cliical egligece claims as at ed of were i excess of 2 billio. A retrospective study of patiet records i two Eglish hospitals foud 10.8 per cet of patiets experieced a adverse icidet; of which aroud half (5.2 per cet) were judged to have bee prevetable. These adverse icidets caused permaet impairmet i six per cet ad cotributed to death i eight per cet of cases 2. Our aalysis of trust surveys foud that 169 trusts were able to provide data o the umber of deaths as a result of patiet safety icidets. This showed that i there were some 2,181 deaths recorded but it is ackowledged that there is sigificat uder reportig of deaths ad serious icidets. Other published estimates of death as a result of patiet safety icidets rage from 840 to 34,000 but i reality the NHS simply does ot kow. A iteratioal review of ie retrospective studies of patiet records foud that the average icidece of adverse evets was 8.9 per cet (rage from per cet). Source: Natioal Audit Office a Termiology developed by the Natioal Patiet Safety Agecy to be used istead of the terms adverse evet or cliical error. A Safer Place for Patiets: Learig to improve patiet safety

8 summary 2 There are umerous stakeholders with a role i keepig patiets safe i the NHS, may of whom require trusts to report details of patiet safety icidets ad ear misses to them (Figure 2). However, a umber of previous Natioal Audit Office reports have highlighted cocers that the NHS has limited iformatio o the extet ad impact of cliical ad o-cliical icidets ad trusts eed to lear from these icidets ad share good practice across the NHS more effectively (Appedix 1). 3 I 2000, the Chief Medical Officer s report A orgaisatio with a memory 1, idetified that the key barriers to reducig the umber of patiet safety icidets were a orgaisatioal culture that ihibited reportig ad the lack of a cohesive atioal system for idetifyig ad sharig lessos leart. 4 I respose, the Departmet published Buildig a safer NHS for patiets 3 detailig plas ad a timetable for promotig patiet safety. The goal was to ecourage improvemets i reportig ad learig through the developmet of a ew madatory atioal reportig scheme for patiet safety icidets ad ear misses. Cetral to the pla was establishig the Natioal Patiet Safety Agecy to improve patiet safety by reducig the risk of harm through error. The Natioal Patiet Safety Agecy was expected to: collect ad aalyse iformatio; assimilate other safety-related iformatio from a variety of existig reportig systems; lear lessos ad produce solutios. 5 We therefore examied whether the NHS has bee successful i improvig the patiet safety culture, ecouragig reportig ad learig from patiet safety icidets. Key parts of our approach were a cesus of 267 NHS acute, ambulace ad metal health trusts i Autum 2004, followed by a re-survey i August 2005 ad a omibus survey of patiets (Appedix 2). We also reviewed practices i other idustries (Appedix 3) ad iteratioal healthcare systems (Appedix 4), ad the Natioal Patiet Safety Agecy s progress i developig its Natioal Reportig ad Learig System (Appedix 5) ad other related activities (Appedix 6). Overall coclusio 6 A orgaisatio with a memory 1 was a importat milestoe i the NHS s patiet safety ageda ad marked the drive to improve reportig ad learig. At the local level the vast majority of trusts have developed a predomiatly ope ad fair reportig culture but with pockets of blame ad scope to improve their strategies for sharig good practice. Ideed i our re-survey we foud that local performace had cotiued to improve with more trusts reportig havig a ope ad fair reportig culture, more trusts with ope reportig systems ad improvemets i perceptios of the levels of uder-reportig. At the atioal level, progress o developig the atioal reportig system for learig has bee slower tha set out i the Departmet s strategy of ad there is a eed to improve evaluatio ad sharig of lessos ad solutios by all orgaisatios with a stake i patiet safety. There is also o clear system for moitorig that lessos are leared at the local level. Specifically: a b c The safety culture withi trusts is improvig, drive largely by the Departmet s cliical goverace iitiative 4 ad the developmet of more effective risk maagemet systems i respose to icetives uder iitiatives such as the NHS Litigatio Authority s Cliical Negligece Scheme for Trusts (Appedix 7). However, trusts are still predomiatly reactive i their respose to patiet safety issues ad parts of some orgaisatios still operate a blame culture. All trusts have established effective reportig systems at the local level, although uder-reportig remais a problem withi some groups of staff, types of icidets ad ear misses. The Natioal Patiet Safety Agecy did ot develop ad roll out the Natioal Reportig ad Learig System by December 2002 as origially evisaged. All trusts were liked to the system by 31 December By August 2005, at least 35 trusts still had ot submitted ay data to the Natioal Reportig ad Learig System. Most trusts poited to specific improvemets derived from lessos leart from their local icidet reportig systems, but these are still ot widely promulgated, either withi or betwee trusts. The Natioal Patiet Safety Agecy has provided oly limited feedback to trusts of evidece-based solutios or actios derived from the atioal reportig system. It published its first feedback report from the Patiet Safety Observatory i July A Safer Place for Patiets: Learig to improve patiet safety

9 summary 2 The stakeholders i patiet safety While the patiet is at the cetre of the safety ageda, there are may people ad a large umber of orgaisatios with a role i the maagemet of risk of uiteded harm. Several of these orgaisatios may require a report of the same icidet at the same time. Royal Colleges Patiets Associatio Professioal associatios ad trade uios Professioal regulatory bodies Idepedet Complaits Advisory Service Healthcare Commissio Health ad Safety Executive 1 Patiet Patiet Advice ad Liaiso Service Chief Executive Cliicias Trust Board Risk Maagemet departmet 1 Cliical Goverace committee Strategic health authority 1 Police 1 Coroer 1 Metal Health Act Commissio 1,2 Moitor Departmet of Health 1 NHS Cliical Goverace Support Team 2 Serious Hazards of Trasfusio Safety 1 Natioal Patiet Safety Agecy 1 Health Protectio Agecy 1 NHS Estates 1,2 Natioal Cliical Assessmet Authority 2 Natioal Istitute for Cliical Excellece Medicies ad Healthcare products Regulatory Agecy 1 NHS Litigatio Authority 1 trust level local level atioal level Source: Natioal Audit Office NOTES 1 Orgaisatios to which a patiet safety icidet will be reported, either o a volutary or statutory basis (see also Figure 14). 2 Followig the Departmet of Health s review of Arm s Legth Bodies, the fuctios of these orgaisatios have bee or are i the process of beig, trasferred to other bodies. A Safer Place for Patiets: Learig to improve patiet safety 3

10 summary The culture withi NHS trusts is ow more ope ad fair 7 A just ad fair culture is a key requiremet if reportig ad learig are to be improved. All trusts have cotiued to build o ad develop their cliical goverace arragemets, but with varyig degrees of success. Most trusts have succeeded i reducig the blame culture. By helpig trusts to deal more effectively with poorly performig doctors, the Natioal Cliical Assessmet Authority b is cotiuig to cotribute to the developmet of a more ope ad fair culture ad, as a result, suspesios have icreasigly bee avoided. However, the support provided applies oly to doctors. I 2004, the Natioal Patiet Safety Agecy produced guidace aimed at supportig trusts i assessig their safety culture ad promulgated a tool to prompt trusts to focus o why the patiet safety icidet happeed, ad ot who was to blame, ad to adopt a systematic approach to decisios about the employee ivolved (Appedix 6). 8 Withi local orgaisatios strog leadership ad goverace at chief executive ad board level is crucial. Virtually all chief executives provided examples of their persoal ivolvemet with the patiet safety ageda. Sice 2001, over 130 trust boards or key members of trust boards have egaged with the Board Developmet Team at the NHS Cliical Goverace Support Team. More recetly o-executive trust board members from 113 trusts have udertake Leadership i Patiet Safety Traiig provided by the NHS Appoitmets Commissio ad the Natioal Patiet Safety Agecy. 9 A orgaisatioal top dow approach o its ow is ot sufficiet. The regulatory bodies, Royal Colleges ad the other professioal bodies have all placed greater emphasis o idividual resposibility ad accoutability for patiet safety. Although few trusts provided icetives for staff to improve patiet safety, 93 per cet ivolved them i idetifyig priorities ad desigig solutios. 10 As ie out of te NHS employees work i teams 6, effective commuicatio betwee staff is importat to reduce the risk of uiteded harm to patiets, yet trusts ofte cite failure i commuicatio as a reaso for a icidet. Commuicatig opely with patiets ad carers is also essetial but oly 24 per cet of trusts were routiely iformig patiets whe a icidet that they had bee ivolved i was reported to the trust. 11 To provide evidece that NHS orgaisatios were doig their reasoable best to maage themselves so as to protect patiets, staff ad the public agaist risks of all kids, the Departmet established the madatory Cotrols Assurace Stadards i Trusts had to udertake a self-assessmet agaist defied criteria. For the Risk Maagemet System stadard these criteria icluded board accoutability, adverse icidet reportig ad complaits ad claims hadlig. Over the five years of its operatio average compliace icreased from 52 per cet to 87 per cet. 12 I August 2004, the Departmet aouced that key elemets of the Cotrols Assurace Stadards would be icorporated i a ew performace assessmet framework based aroud a set of core ad developmetal stadards (Stadards for Better Health), with compliace evaluated by the Healthcare Commissio. Safety is the first of seve domais i these stadards (Appedix 7). 13 Assessmet of trusts risk maagemet systems udertake o behalf of the NHS Litigatio Authority has also provided a strog icetive for trusts to improve their reportig ad learig systems (Appedix 7). Each year sice the operatio of the Cliical Negligece Scheme for Trusts may trusts have gradually improved their risk maagemet systems ad see their cotributios reduced accordig to the level of compliace achieved (Figure 4 page 19). Local reportig has improved but there have bee delays i establishig a effective atioal system 14 Uless trusts are cofidet that their reportig systems idetify the mai risks to patiet safety they caot target itervetios effectively. All trusts had implemeted itegrated reportig systems as part of risk maagemet. By 2005, the majority of these reportig systems were either cofidetial (34 per cet) or ope (63 per cet) with 38 per cet of these trusts also providig a aoymous reportig route for use by staff who may be fearful of raisig their cocers. Reported icidets were aalysed at the local level with relevat iformatio passed oto oe or more of aroud 30 orgaisatios. b The Natioal Cliical Assessmet Authority was established as a special health authority i 2001 to provide support ad expert advice ad a assessmet service to NHS orgaisatios that are faced with cocers over the performace of idividual doctors ad detists (Appedix 2 details our previous work o this issue). Followig the Departmet s Arm's Legth Bodies Review, from April 2005, the Natioal Cliical Assessmet Authority became part of the Natioal Patiet Safety Agecy ad was reamed the Natioal Cliical Assessmet Service. 4 A Safer Place for Patiets: Learig to improve patiet safety

11 summary 15 Sevety-eight per cet of trusts told us that their emphasis o ecouragig reportig was havig a positive impact o the umber of icidets reported ad the total umber of patiet safety icidets reported withi trusts has rise year o year. Despite the geeral icrease i reportig, trusts ackowledged that a substatial umber of icidets still go ureported (trusts o average estimated that 22 per cet of icidets go ureported, maily medicatio errors ad icidets leadig to serious harm). Reportig of ear misses was also low, maily due to differet perceptios of what costitutes a ear miss. Traiig ca help improve levels of reportig but there has bee o evaluatio of the efficacy of courses ad o system for accreditig those curretly i use. 16 Healthcare orgaisatios i other coutries, havig compared the merits of aoymous ad cofidetial reportig, have geerally opted for cofidetial reportig. The Departmet proposed a cofidetial scheme, madatory for trusts, to record patiet safety icidets ad ear misses across the NHS 3, however the Natioal Patiet Safety Agecy recommeded the developmet of two reportig systems, oe which would iterface with trusts icidet reportig systems, but with the idetity of the patiet ad perso reportig stripped out, ad the secod, a totally aoymous volutary e-form which ca be shared with the trust if the perso makig the report agrees. 17 The roll out of the Natioal Patiet Safety Agecy s Natioal Reportig ad Learig System has take two years loger tha origially evisaged. By 31 December 2004 all trusts had the techology to lik to the system but may still had to map details from their local system to the atioal system. By the ed of March 2005, some 170 acute, ambulace ad metal health trusts had reported 79,220 icidets (a further 6,122 icidets were reported by primary care trusts makig a total of 85,342 patiet safety icidets reported to the Natioal Reportig ad Learig System up to March 2005). 18 The e-form was lauched i September 2004 ad by April 2005, 108 reports had bee made usig this route. Whilst the Natioal Patiet Safety Agecy does ot kow how may staff will make use of the e-form, it believes this is a rich source of iformatio for learig 5 ad provides a safety et for those who are too frighteed to report to their local system. Five trusts told us that they do ot wat a aoymous system as this udermies local reportig ad learig ad that they would discourage use of the e-form. Twety-ie trusts are actively ecouragig the use of the e-form. 19 Buildig a safer NHS for Patiets 3 required the NHS to establish agreed defiitios of icidets for the purposes of reportig, gradually movig to a iteratioal stadardised taxoomy (descriptio ad classificatio of icidets). The Natioal Patiet Safety Agecy developed its taxoomy i cosultatio with trusts but it is ulike may trusts taxoomies ad, i order to lik to the atioal system, trusts had to map it to their ow. At the time of our survey 82 per cet of trusts had had difficulties with the mappig exercise, ad 17 per cet of these said that they had experieced major difficulties. Two-thirds of trusts told us that the atioal taxoomy was ot specific eough so were cotiuig to use their ow. It is also differet from taxoomies used i other coutries. The World Health Orgaisatio is curretly developig a iteratioal taxoomy which would require the Natioal Patiet Safety Agecy ad trusts to make chages to their taxoomies if they are to comply. 20 The Natioal Patiet Safety Agecy worked with the Medicies ad Healthcare products Regulatory Agecy i order to test the feasibility of a sigle data etry poit for reports of errors ivolvig medical devices. However, this did ot prove possible due to the statutory resposibilities of the Medicies ad Healthcare products Regulatory Agecy ad the requiremets of the Natioal Patiet Safety Agecy. Ideed there has bee o further developmet i this area ad trusts are still required to report the same icidet to more tha oe orgaisatio. 21 Give that the Departmet s aim was to ecourage reportig, o targets were set for reducig the umber of reported patiet safety icidets. Rather, the Departmet set targets for reducig the icidece of four specific types of errors (maladmiistratio of spial ijectios; serious error i the use of medicies; suicides by metal health ipatiets as a result of hagig from o-collapsible rails ad harm i obstetrics ad gyaecology). Whilst there have bee o reports of icidets ivolvig the first type of error, there are limited data to judge whether the target o medicatio errors has bee realised ad mixed messages o progress agaist the targets o suicide as a result of hagig ad obstetrics ad gyaecology. For example, although egligece claims for obstetrics ad gyaecology appear to be reducig, the Healthcare Commissio highlighted cocers about the safety of some materity services 7, 8. A Safer Place for Patiets: Learig to improve patiet safety 5

12 summary A umber of local ad atioal systems are i place for aalysig ad sharig lessos leart, but most are uder-used 22 Most trusts did aalyse icidet reports ad other iformatio. Ideed most had bee carryig out i depth ivestigatios of icidets at the local level for a umber of years. Sevety-six per cet of trusts told us that they were ow ecouragig staff to use the Natioal Patiet Safety Agecy s root cause aalysis tool, with may otig that it had helped to improve the quality ad cosistecy of i-depth ivestigatios. A umber of trusts remarked that moitorig ad ivestigatig icidets created additioal demads o busy seior staff, ad cosequetly they did ot always coduct a full root cause aalysis of all serious icidets. The quality of reports o ivestigatios was also very variable ad recommedatios were rarely actioed by orgaisatios outside the trust i which the evet had occurred. 23 Dissemiatio of learig ad the developmet of solutios was patchy ad there was also o systematic moitorig to esure implemetatio withi the trust. Cliical audit ca be a effective way to evaluate whether improvemets are beig implemeted but a umber of Natioal Audit Office reports have highlighted cocers about the limited extet ad coverage of cliical audit (Appedix 1). The Commissio for Health Improvemet reported i 2004 that this was still uder-developed i may trusts Over half of trusts reported that patiets were ivolved i both idetifyig safety priorities ad developig ways to prevet recurrece. However, oly six per cet of patiets we surveyed said they were cosulted about how the safety icidet they experieced could be preveted from happeig to someoe else. 25 Niety-ie per cet of trusts idetified specific itervetios that they had developed to address patiet safety issues (some are described i this report). However, few trusts have carried out ay cost beefit aalysis of itervetios/solutios to improve patiet safety. Give the estimated 2 billio cost of extra bed days due to icidets ad the potetial litigatio costs, we cosider that i may circumstaces the cost of itervetio is likely to be far less tha the cost of failig to prevet the icidet. 26 At a regioal level, half the strategic health authorities used cliical goverace etworks to dissemiate learig ad i some areas they have itroduced patiet safety learig sets. However, a umber told us they were ill-equipped to share lessos ad may felt that they did ot have the capacity or capability to moitor the implemetatio of good practice. There is also a risk that as foudatio trusts are ot required to report to strategic health authorities they will miss out o the sharig of learig. Other sources of learig are orgaised etworks, like those for cacer ad coroary heart disease, ad ambulace trusts use the Ambulace Service Associatio. Sice summer 2004, the Natioal Patiet Safety Agecy s 28 Patiet Safety Maagers have bee workig with most trusts to help share good practice. 27 Oe way of dissemiatig iformatio about ecessary chages is the Departmet s Safety Alert Broadcast System. The Departmet, the Medicies ad Healthcare products Regulatory Agecy, NHS Estates c ad the Natioal Patiet Safety Agecy issue safety alerts to trusts for them to act upo withi a defied timescale. Durig , trusts received 93 alerts through the System. Trusts told us that there was a lack of clarity i the ratioale for the decisio to release iformatio as a alert ad some felt that a umber of these alerts did ot tell them aythig ew. All wated better liks ad commuicatio betwee the bodies that issue otices via the Safety Alert Broadcast System. The Chief Medical Officer s aual report 10 idetified cocers that compliace with alerts was slow ad some trusts which reported compliace were subsequetly foud to be o compliat. 28 The Departmet expected that the ew atioal reportig system for learig would brig about chages at trust ad atioal levels, through the aalysis of icidets ad the subsequetly their root causes. As at April 2005, the Natioal Patiet Safety Agecy had issued limited feedback to trusts of lessos emergig from their reports to the atioal system. Although the Natioal Reportig ad Learig System has the capacity to collect cotributory factors, these are ot madatory ad the itetio is to idetify treds that ca the be aalysed i greater detail. Trusts told us they were cocered that iformatio flow was oe-way to the Natioal Patiet Safety Agecy ad the geeral perceptio was that the Natioal Reportig ad Learig System was simply a iformatio collectio system. The July 2005 report from the Patiet Safety Observatory should start to address this perceptio. 5 c NHS Estates, resposibilities for health ad safety eviromet alerts are beig trasferred to the Departmet as part of the Arm s Legth Bodies Review. 6 A Safer Place for Patiets: Learig to improve patiet safety

13 summary 29 The Departmet evisaged that the Natioal Patiet Safety Agecy would assimilate other safety related iformatio from a variety of existig reportig systems ad other sources such as NHS complaits, litigatio, Natioal Cofidetial Equiries ad atioal audits (Figure 3). We foud that there has bee limited progress o assimilatig ad dissemiatig lessos from these differet sources of iformatio. Furthermore, the idividual orgaisatios resposible for litigatio ad complaits have util recetly ot made as much use of the valuable data they collect as they might to help trusts avoid similar icidets. 30 The Natioal Programme for Iformatio Techology i the NHS, beig delivered by the Departmet s agecy NHS Coectig for Health, has a crucial role i developig the techology to esure that relevat iformatio ca be stored securely ad accessed readily. A key compoet, the Natioal Care Record, has sigificat potetial to improve safety as lost or poorly completed records are a major cotributory factor to patiet safety icidets. Techology will also facilitate retrospective audits, improve access to guidace ad reduce the risks of icorrect drug prescribig ad dosages. I time, trusts idividual reportig systems will be itegrated ito the Natioal Programme. The Natioal Patiet Safety Agecy is workig with NHS Coectig for Health s patiet safety sub-group to take this forward. 3 Progress towards the plaed atioal reportig system for learig ad expected feedback routes Feedback Staff NHS Trusts Patiets/carers Natioal Patiet Safety Agecy s Natioal Reportig ad Learig System Stadardised Iformatio; Agreed defiitios; Miimum data set; Stadard format Natioal Patiet Safety Agecy s Patiet Safety Observatory Iteratioal collaboratio with Australia, the Uited States of America Iformatio from all other major existig adverse evet reportig systems feed i Medicies ad Healthcare products Regulatory Agecy - medical devices ad adverse drug reactios NHS Litigatio Authority - cliical egligece Health Protectio Agecy - ifectio surveillace NHS Estates (ow part of the Departmet) - health ad safety eviromet Natioal Istitute for Cliical Excellece - Cofidetial Equiries (ow part of the Natioal Patiet Safety Agecy s resposibilities) Healthcare Commissio - complaits Ombudsma - complaits Health ad Safety Executive - reportig of ijuries, diseases ad dagerous occurreces regulatios (1995) Takig place Yet to routiely take place Route i place but ot used A Safer Place for Patiets: Learig to improve patiet safety

14 coclusios ad recommedatios For the Departmet: a b The Departmet established a umber of arm s legth bodies with a role i keepig patiets safe. The Departmet eeds to use its arm s legth bodies performace moitorig system to establish appropriate actios ad milestoes to: ehace ad sustai the developmet of a effective safety culture withi NHS trusts; improve the reliability ad completeess of trust icidet reportig ad for dissemiatig the results of atioal reportig back to trusts; provide effective feedback of lessos ad solutios to improve safety. The Natioal Cliical Assessmet Authority has played a key role i improvig the maagemet of suspesios of doctors but other cliical staff are ot covered by the Authority s remit. I the Govermet s respose to the previous Committee of Public Accouts recommedatio d to cosider extedig the Authority s remit the Departmet told the Committee that the fuctios of the Natioal Cliical Assessmet Authority were beig trasferred to the Natioal Patiet Safety Agecy from 1 April 2005, ad that this cosideratio was therefore o hold. Give that the trasfer is ow complete, the Departmet should ow respod fully to the Committee s recommedatio to cosider extedig the role of the Natioal Cliical Assessmet Service to other cliical staff. c d It is imperative that patiet safety becomes a core part of professioal traiig, icludig helpig cliical staff uderstad their resposibility for patiet safety ad the beefits of workig i a ope ad questioig eviromet. The Departmet eeds to build o its work with the professioal regulatory bodies ad Royal Colleges to better embed patiet safety traiig i all pre-registratio professioal traiig curricula ad to raise the profile of patiet safety issues i post-registratio traiig. Despite the ratioalisatio evisaged i Buildig a safer NHS for patiets 3, trusts are still required to report the same icidet to umerous atioal bodies ad revise their data sets to capture ew iformatio which those bodies require. Wherever possible, icidets should oly be reported oce ad, as trusts move to electroic reportig, the Departmet should explore the possibility of recommedig a sigle etry poit, for example via the Natioal Programme for Iformatio Techology i the NHS. As a miimum the Departmet should cosult with NHS Coectig for Health, the NHS Health ad Social Care Iformatio Cetre, the Natioal Patiet Safety Agecy, the Medicies ad Healthcare products Regulatory Agecy ad the relevat sigatories of the Healthcare Ispectio Cocordat e to idetify the scope to ratioalise the umber of data etry poits. d The maagemet of suspesios of cliical staff i NHS hospitals ad ambulace trusts i Eglad ; Forty-seveth Report of Sessio (HC 296). e A Cocordat betwee the Healthcare Commissio ad ie other bodies ispectig, regulatig ad auditig healthcare was lauched i Jue The aim was to reduce overlap ad duplicatio of ispectio, improve co-ordiatio, support improvemets i quality ad make ispectios proportioate trasparet ad accoutable. A Safer Place for Patiets: Learig to improve patiet safety

15 summary For the Natioal Patiet Safety Agecy: e f May trusts ad orgaisatios ivolved i collectig data o patiet safety icidets cosider that the taxoomy developed by the Natioal Patiet Safety Agecy is ot specific eough for their purposes. The Natioal Patiet Safety Agecy should work to adopt a taxoomy that ideally correspods to the iteratioal taxoomy beig developed by the World Health Orgaisatio, but as a miimum should gai buy-i from all trusts ad other bodies requirig reports o icidets to a madatory miimum data set to esure that there is cosistecy i the data collected at local ad atioal levels. May trusts are questioig the value of sedig data to the Natioal Reportig ad Learig System give the lack of feedback ad would like to see more of a emphasis o solutios. The Natioal Patiet Safety Agecy eeds to agree with the Departmet a regular publicatio timetable, so that opportuities to sesatioalise the data are reduced, ad provide examples of how the NHS is learig from the data. Oe optio is to produce quarterly updates so that it becomes stadard. The Natioal Patiet Safety Agecy eeds to expedite its evaluatio ad feedback programme ad focus o developig solutios to atiowide problems to mitigate the risk that trusts will stop sedig data to the Natioal Reportig ad Learig System. These solutios should be accompaied by a sample busiess case which trusts ca the customise. g h i There is little dissemiatio of learig betwee most trusts. The Natioal Patiet Safety Agecy s Patiet Safety Maagers should establish formal systems to capture learig i specialties ad share learig across other teams ad trusts at both local ad atioal level. I additio they should ivestigate the possibility of establishig local etworks similar to those for cacer, which will have the potetial to improve the delivery of patiet-cetred care by dissemiatig learig about the whole patiet jourey. There is curretly o scheme for accreditatio or bechmarkig of patiet safety traiig; thus trusts have o assurace that the traiig they commissio is a good product. The Natioal Patiet Safety Agecy should look to other idustries ad together with the NHS Istitute for Learig, Skills ad Iovatio, develop a accreditatio scheme for all patiet safety traiig supplied by exteral providers. It should also evaluate traiig programmes operated by trusts to build up a library of good practice to eable trusts to customise their traiig to best effect. NHS Coectig for Health has asked the Natioal Patiet Safety Agecy to help assure the specificatio for the Natioal Programme for Iformatio Techology i the NHS to esure that patiet safety is iheret throughout the system. I takig this forward the Natioal Patiet Safety Agecy should esure that Coectig for Health fully uderstads ad builds o the lessos from the developmet ad roll out of the Natioal Reportig ad Learig System. A Safer Place for Patiets: Learig to improve patiet safety

16 For the Healthcare Commissio j k l Safety alerts are a importat mechaism for implemetig solutios ad we support the coclusios i the Chief Medical Officer s recet report 10. Iformatio o compliace should be made public ad the Healthcare Commissio should place special focus o verificatio of NHS trusts compliace whe assessig performace agaist the Stadards for Better Health. No sigle NHS orgaisatio is resposible for auditig implemetatio of best practice solutios for patiet safety issues. The Healthcare Commissio should esure that i assessig the safety domai it builds i assessmet criteria that evaluate how well solutios have bee implemeted. Iformatio from complaits ad litigatio is still greatly uder-exploited as a learig resource. The Healthcare Commissio eeds to expedite its i-depth aalysis of iformatio from the NHS Complaits system ad share lessos o a regular basis. The Healthcare Commissio eeds to work with the NHS Litigatio Authority ad the Natioal Patiet Safety Agecy to agree how best to share the data ad where the resposibility lies for idetifyig key lessos ad providig trusts with feedback from these aalyses. For NHS acute, metal health ad ambulace trusts m Despite improvemets i safety culture may NHS employees still fear blame or uequal treatmet if they report icidets ad this remais a major barrier to icreasig accurate ad hoest reportig. There is a eed for trusts to re-eforce their commitmet to a ope ad fair reportig culture ad to support staffig iitiatives to improve. Trusts should assess their safety culture usig oe of the established tools, such as those listed i the Seve steps to patiet safety 11, ad implemet a actio pla to address the idetified issues. Fiacial problems ad staff shortages ca push patiet safety dow the list of trusts priorities. Although the potetial avoidable costs of patiet safety icidets is estimated to be as much as o p q 1 billio 1, some areas of ivestmet are likely to have a bigger pay back tha others. Trusts should esure that fudig for maagig ad improvig patiet safety reflects the orgaisatio s risk register, ad require their patiet safety leads to develop aual busiess cases that demostrate the opportuity costs of the improvemets they pla to make, where relevat these should build o the solutios ad accompayig busiess cases developed by the Natioal Patiet Safety Agecy. Patiets have little ivolvemet i the idetificatio of patiet safety priorities ad i the desig of solutios i most trusts. Trusts eed to egage patiets more i idetifyig importat patiet safety issues ad desigig solutios ad make better use of iformatio gaied through cotacts with Patiet Advice ad Liaiso Services. Trusts should esure that they fully ivestigate complaits ad litigatio claims ad aalyse treds i both so as to lear from them. Uder-reportig is a problem i some staff groups more tha others ad there is a perceptio amogst staff that ot all employees take resposibility for patiet safety reportig. Trusts should target specific traiig ad feedback o those groups of staff that are less likely to report. They should liaise with the Natioal Patiet Safety Agecy to idetify ad lear lessos from trusts which have achieved high reportig rates ad also to build o the lessos from atioal iitiatives to ecourage reportig such as the work beig doe by the Agecy o ecouragig juior doctors to report. Near misses are geerally uder-reported ad iformatio o outcomes, particularly death ad serious harm is poor. Trusts should esure that their reportig policies clearly defie a ear miss ad should develop strategies to ecourage more staff to report them to make sure potetial serious icidets that were preveted are ot overlooked. Trust should also triagulate iformatio from various data sources such as complaits, claims, coroers reports etc to esure that all deaths ad serious harm as a result of a patiet safety icidet are recorded o their icidet reportig system. 10 A Safer Place for Patiets: Learig to improve patiet safety

17 summary A Safer Place for Patiets: Learig to improve patiet safety 11

18 part oe Part oe The safety culture withi NHS trusts is ow more ope ad fair 12 A Safer Place for Patiets: Learig to improve patiet safety

19 part oe 1.1 Although the great majority of patiet care i the NHS is of a high stadard, the umber ad complexity of patiet itervetios meas that patiets ca sometimes suffer uiteded harm. I 1997, the Govermet itroduced a te year programme to cotiuously improve the overall stadard of cliical care; cetral to this was the cliical goverace iitiative. By 2000, the NHS was still failig to lear from thigs that wet wrog ad had limited systems i place to put thigs right. A orgaisatio with a memory 1 therefore idetified the coditios eeded to improve people s cofidece i the NHS. It advocated a chage i the safety culture, from oe that was essetially based o fear ad blame, to a ope ad fair reportig culture to trasform the NHS ito a effective learig orgaisatio. 1.2 I Jue 2000, the Departmet accepted all the recommedatios of A orgaisatio with a memory 1 ad made a commitmet to implemet them i The NHS Pla 12. The 2001 policy documet, Buildig a safer NHS for patiets 3, set out how the Departmet plaed to take forward the patiet safety ageda ad the timetable for implemetig the idetified chages. It advocated that patiet safety ad risk reductio should be at the heart of the framework for improvig quality of care, icludig protectio agaist poorly performig cliicias. A key actio was the establishmet of the Natioal Patiet Safety Agecy i July This Part of the report examies the progress i developig a NHS safety culture. I particular whether: trusts had created a eviromet i which staff could report cocers without fear; commuicatio with staff ad patiets was two-way ad effective team-workig predomiated; there was a high profile lead o the issue; ad there was itegrated risk maagemet. Progress has bee made both locally ad atioally i ecouragig a ope ad fair culture 1.3 To establish a safety culture a orgaisatio must build a climate where staff feel they ca report cocers without fear ad they uderstad that they are accoutable for uacceptable behaviours. Eighty per cet of the seior cliical ad o-cliical maagers i a YouGov poll 13 said creatig a culture that ecourages reportig ad avoids blame was oe of the most beeficial ways of improvig patiet safety. We foud that 97 per cet of trusts had made a clear statemet of support for a ope ad fair culture, ad aroud three-quarters of them dissemiated it to staff by maagemet cascade ad/or through writte commuicatio. A Safer Place for Patiets: Learig to improve patiet safety 13

20 part oe 1.4 Almost all trusts reported that they had made progress i reducig the culture of blame. Our aalysis of the specific actios that trusts had take to improve their patiet safety culture showed that the most commo were: the itroductio or icreased provisio of traiig o patiet safety (35 per cet); ad the employmet or re deploymet of staff to improve risk maagemet (22 per cet). By July 2005, 31 per cet of trusts felt that they had a ope ad fair culture throughout the orgaisatio (compared with 23 per cet i 2004) ad 65 per cet that they had a predomiatly ope ad fair culture (72 per cet i 2004). 1.5 We also asked trusts to rate their positio i 2005 compared with 2004 o a scale of 1-7 (where 1 is predomiatly a blame culture, 4 is movig towards a ope ad fair culture but pockets of blame exist i some major areas of the trust ad 7 is predomiatly a ope ad fair culture throughout the trust). The average score i 2005 was 5.66 compared with 4.73 i Overall, 68 per cet of trusts reported that they had improved, 28 per cet that they had stayed the same but two per cet felt that they got worse. Executive directors of patiet safety may be uder-estimatig the prevalece of the blame culture as oly half (51 per cet) of trusts had actually evaluated their safety culture (mostly commoly through their staff survey ad exteral audits or assessmets). 1.6 I 2001, because of trusts over-reliace o discipliary measures, the Departmet set up the Natioal Cliical Assessmet Authority to provide quick objective assessmets o doctors performace ad to place a greater emphasis o usig educatio ad traiig to address problems. Our report o the maagemet of suspesios of cliical staff 14 highlighted trusts difficulties i maagig poor performace ad that referrig a case to the Natioal Cliical Assessmet Authority, at a early stage, helped to reduce the perceptio that the trust operated a blame culture. Other cliical staff such as urses were ot give the same level of support ad we recommeded that the work of the Natioal Cliical Assessmet Authority should be exteded to cover all cliical staff. Sice 2003, the Natioal Cliical Assessmet Authority f has cotiued to cotribute to the developmet of a more ope ad fair culture ad through its work suspesios have bee avoided i a growig umber of cases. 1.7 Surveys of urses ad other o-medical staff highlighted that they perceived that the blame culture cotiues to exist i the NHS. Whilst 25 per cet of respodets to a Uiso survey 15 (2003) said that the culture withi their trust had improved sice 2000, a third of respodets still believed that their trust would ot wat to kow about a serious problem affectig services. The Royal College of Nursig 16 foud a perceptio remaied that there was sigificat disparity betwee the treatmet of doctors ad urses, by both their employer ad the regulatory body, followig a serious patiet safety icidet. The Natioal NHS Staff Survey showed that oly 47 per cet of ambulace persoel felt their employers treated those ivolved i a error, ear miss or icidet fairly ad 26 per cet said their employers blamed or puished staff whe they made errors. Case example 1 shows how oe ambulace service has take steps to address these perceptios ad begu to embed a ope ad fair culture i the Trust. 1.8 Oe of the key targets for the Natioal Patiet Safety Agecy was to support a NHS culture that is ope ad fair. Its Seve steps to patiet safety 11 (February 2004) provides a checklist ad refereces a umber of available tools to help trusts assess their safety culture (Appedix 6). Forty-five per cet of trusts had actively dissemiated this guidace to staff i some form. Seve steps to patiet safety 11 also drew attetio to the Icidet Decisio Tree, a iteractive web-based tool aimed at helpig trusts focus o possible system failures ad trust-wide weakesses rather tha who was to blame. Trusts told us the tool had helped esure there was fairer ad cosistet maagemet of staff ivolved i reported patiet safety icidets or ear misses. Trusts are ow more likely to be fosterig ope ad questioig commuicatio betwee staff i teams 1.9 High performig teams with collective resposibility for their actios are importat if trusts are to deliver safe ad effective care. Nie out of te NHS staff work as part of a team 6 but most trusts idetified that a lack of commuicatio withi teams was oe of the root causes of patiet safety icidets. Some had therefore cocetrated o makig commuicatio i multi discipliary teams more ope ad questioig to reduce the risk of f Uder the Arm s Legth Bodies Review, the Natioal Cliical Assessmet Authority became part of the Natioal Patiet Safety Agecy from April 2005 ad was reamed the Natioal Cliical Assessmet Service. 14 A Safer Place for Patiets: Learig to improve patiet safety

21 part oe case example 1 North East Ambulace Service NHS Trust Situatio: Prior to the merger of the Northumbria ad Durham Ambulace Services i 1999, the Trusts approach to the maagemet of staff ivolved i patiet safety icidets had bee cofrotatioal, ofte ivolvig suspesio from duty. Actio: Followig the merger, the North East Ambulace Service NHS Trust has moved towards a o-discipliary approach to ivestigatig such icidets. I respose to our 2002 cesus for the Maagemet of suspesios of cliical staff i NHS hospital ad ambulace trusts i Eglad 14, the Trust idicated that it was movig towards a fair-blame culture ad had itroduced a pael system to miimise the eed to take fial actio. Two years o, the system is well embedded i the Trust. Outcome: I the evet of a icidet requirig a ivestigatio, staff are called to a variatio to cliical practice pael meetig. The pael icludes the ambulace crew ivolved i the icidet uder ivestigatio, a uio represetative ad represetatives from Trust maagemet. The trade uio was closely ivolved i the developmet of the pael, ad the opportuity to have a uio represetative at pael meetigs was a importat factor i staff acceptace of the process. If the pael fids that a staff member has committed a error, the Trust esures that the idividual takes resposibility ad the Trust would take further actio, such as providig re-traiig, if required. This pael process, combied with cotiuig professioal developmet traiig, works to esure staff are aware of their professioal resposibilities. The developmet of this more collaborative approach has had promisig results ad has bee a key step i embeddig a ope ad fair culture withi the Trust. Staff are ow much more cofidet that they ca report icidets that occur without fear of disproportioate repercussio or puishmet. Source: Natioal Audit Office uitetioal harm (Case example 2 overleaf). Ideed, teams from 83 trusts have atteded the Team Resource Maagemet ad Patiet Safety Programme ru by the NHS Cliical Goverace Support Team. The programme develops capacity for team workig by drawig o experieces from other idustries, particularly aviatio, ad examiig the impact of persoality ad behaviour o co-operative workig. There is still more to do to achieve a fully ope ad fair culture with regard to commuicatig with patiets 1.10 Good practice guidace 17 ecourages trusts to iform patiets whe they are ivolved i a icidet ad cliical staff eed to be traied to develop a ope approach to commuicatig with patiets. I our survey, 69 per cet of trusts had criteria for staff to follow but oly 24 per cet routiely iformed patiets whe they were ivolved i a reported icidet; 6 per cet did ot iform patiets at all. A YouGov poll 13 foud most seior cliical maagers believed patiets ad their families should be told if patiets suffered harm, ad most o-cliical maagers believed that patiets should be told whe there has bee a problem, eve if they suffered o harm Patiets perceptios of the practice of iformig them differed from those of the trusts. Fifty-oe per cet of patiets i our survey said that whe their treatmet had goe wrog, the hospital had iformed them ad 56 per cet were completely satisfied with the explaatios give followig the icidet. Those patiets who were provided with a explaatio of risks ad how to miimise them were less likely to complai or make a claim, with oly 13 per cet goig o to take further actio Patiets are also beig ecouraged to take greater resposibility for their safety. Sevety-three per cet of trusts reported that they provided iformatio to patiets to help them to maitai their ow safety. (Most commo were writte materials to take away (48 per cet) or posters i public areas (38 per cet) ad 42 per cet of trusts stated that they provided oral iformatio as a matter of course). I cotrast, 56 per cet of patiets i our survey said that they had bee iformed about maitaiig their ow safety ad how to miimise their risk of harm. A Safer Place for Patiets: Learig to improve patiet safety 15

22 part oe case example 2 Royal Corwall Hospitals NHS Trust Situatio: The work of theatre teams at the Royal Corwall Hospitals NHS Trust requires a high degree of co-ordiatio ad commuicatio to maitai effectiveess ad safety. A typical theatre team does ot come together i its etirety util the first surgical operatio is uderway ad will ofte disperse as the last patiet leaves theatre. Actio: Two aaesthetists at the Trust were iterested i huma factors research i other idustries ad its applicatio to healthcare. They therefore asked a medical educatioalist to coduct ethographic observatio of theatre teams. The NHS Cliical Goverace Support Team provided the educatioal resources for iductio to huma factors for a etire operatig theatre complex. Followig this, the Natioal Patiet Safety Agecy agreed to fud work to idetify a routie formal approach to team briefig ad debriefig to improve commuicatio ad ehace teamwork. QietiQ (the former Defece Evaluatio ad Research Agecy) were egaged to work with the Trust to develop a team self-review process (a form of structured debriefig that assists surgical teams i collective reflectio o their performace). The process aims to improve teamwork behaviours which the traslates to improved team performace ad risk reductio for the patiet. Ackowledgig positive behaviour ecourages teams to explore solutios iteral to the team. Outcome: Iitially, persoel were self-coscious durig the briefigs, though overall they have reacted positively to the self-review cocept. The team discusses issues aroud team maagemet, safe practice ad shared situatioal uderstadig at the self-review meetigs. I the first week of usig team self-review i the theatres, over 80 learig poits emerged. A umber of these were actioed, particularly those which were mior ad cost-free. For example, idetificatio that there should be a lamiated MRSA policy placed o the theatre door whe a MRSA patiet is i theatre. Prelimiary research udertake by the Theatre Team Resource Maagemet Team at the Royal Corwall Hospital foud that staff i the theatre complex exposed to team self-review showed statistically sigificat improvemet i teamwork climate ad some improvemet i the safety climate (usig the Safety Attitude Questioaire, a reliable ad formally validated research tool used i over 350 hospitals worldwide) tha staff who were ot offered debriefs or did ot atted. Other domais of stress recogitio, workig coditios, maagemet perceptios ad job satisfactio showed little or o chage, possibly explaied by the fact that the Trust was goig through extesive reorgaisatio at the time. We fuded further research by the Trust to evaluate the log term impacts ad beefits of team self-review. The Staff Attitude Questioaire data idetified that: briefig ad debriefig had a positive impact o otechical skills ad patiet safety; pre-sessio briefig was importat for safety ad effective team maagemet (those iterviewed reported that the process improved teambuildig ad commuicatio, ad ehaced preparatio ad aticipatio of potetial problems for theatre lists); ad debriefig was valued as a process by which the teams could lear from problems ecoutered durig lists ad pla how care could be improved i the future. Although time restrictios ad additioal pressig commitmets have limited uiversal uptake, theatre staff have edorsed the cocept of briefig ad debriefig ad extesio of the team self review process. Source: Natioal Audit Office Most trusts have established a clear ad strog focus o patiet safety May trusts are buildig a safer culture through the developmet of leadership 1.13 All but three trusts gave us examples of how the chief executive had persoally bee ivolved i promotig ad drivig forward the patiet safety ageda (Illustrative examples 1). All trusts had a board director resposible for leadig o patiet safety commoly the director of ursig (47 per cet), the medical director (32 per cet) or the chief executive (eleve per cet). A YouGov poll 13 of seior maagers i the NHS foud that most agreed that patiet safety was a high priority for their orgaisatio, though ot top priority The Commissio for Health Improvemet s cliical goverace reviews coducted betwee December 2000 ad March 2004 revealed a lack of good quality cliical leadership i acute, ambulace ad metal health trusts. 9 Durig the last four years the Departmet has provided assistace ad advice o developig effective leadership through the NHS Cliical Goverace Support Team. I particular, it provided a umber of board developmet programmes ad supported challeged orgaisatios to make sustaiable improvemets. By April 2005, trust boards or key members of trust boards from over 130 acute, ambulace ad metal health trusts had egaged with the Board Developmet Team. Betwee November 2004 ad March 2005 the NHS Appoitmets Commissio ad the Natioal Patiet Safety Agecy also provided traiig o Leadership i Patiet Safety to 154 o executive trust board members from 113 trusts. 16 A Safer Place for Patiets: Learig to improve patiet safety

23 part oe Illustrative examples 1 Chief executives ivolvemet i patiet safety The Chief Executive ad most of the executive maagemet team at Staffordshire Ambulace Service NHS Trust cosider that the best way of demostratig leadership ad ivolvemet i the patiet safety ageda is to walk the walk. They therefore go out o call with their paramedics. Staff that we iterviewed felt positively about this direct ivolvemet. The Chief Executive persoally writes to members of staff whe they save lives ad meets with families affected by a serious patiet safety icidet occurrig whilst their relative was i the care of the Trust. At Wirral Hospital NHS Trust the Chief Executive has re-defied the Trust s arragemets for patiet safety ad ivested i the ifrastructure. He persoally chairs the Cliical Goverace Coucil which has agreed ew stadards ad the Trust has a rollig programme to audit ursig stadards. He performace maaged the Trust s achievemet of Level 3 for the Cliical Negligece Scheme for Trusts. The Chief Executive at South Staffordshire Healthcare NHS Trust has egaged Asto Uiversity to coduct team health checks agaist patiet safety research evidece. He also established robust structures ad processes for patiet safety ad improved access to traiig. Source: Natioal Audit Office Survey of NHS acute, ambulace ad metal health trusts I our 2003 report o achievig improvemets through cliical goverace 4 we oted that cliical goverace had improved the way that trusts dealt with quality of care issues ad trust boards had started to become more ivolved i cliical cocers. Most trusts have cotiued to develop the quality ageda through the implemetatio of cliical goverace arragemets ad our 2004 survey revealed that 42 per cet of chief executives raked the Commissio for Health Improvemet s Cliical Goverace reviews as the most sigificat driver for the board to improve patiet safety. Where trust boards had become more egaged with patiet safety, improvemets had also bee drive by the eed to gai assurace to sig off the Statemet o Iteral Cotrol ad their self-assessmet for the Cotrols Assurace Stadards or to secure lower cotributios to the NHS Litigatio Authority to cover egligece claims The Natioal Patiet Safety Agecy has idetified the eed to be see as a leader i its field ad has employed well-respected cliical staff to lead o key areas ad specialties. Most trusts cotact with the Natioal Patiet Safety Agecy has bee through the Patiet Safety Maagers assiged to the 28 strategic health authorities. However, i a survey per cet of juior doctors said they eeded more iformatio about the Natioal Patiet Safety Agecy ad 60 per cet did ot kow of, or were usure of a orgaisatio with a specific remit to improve patiet safety. The Natioal Patiet Safety Agecy lauched a webcast campaig to combat this, froted by Professor Sir Joh Lilleyma, former Presidet of the Royal College of Pathologists ad vice-chairma of the Academy of Medical Royal Colleges. The follow-up survey showed that 70 per cet of respodets still eeded to kow more about the Natioal Patiet Safety Agecy ad 18 per cet were uaware of its existece. Staff are ow more ivolved i improvig patiet safety 1.17 Staff were geerally positive about the priority give to patiet-focused care by their employer 6 but visio ad leadership aloe are isufficiet. Hippocrates golde rule that healers should first, do o harm remais a cetral teet of NHS healthcare. Idividual staff eed therefore to take resposibility for patiet safety ad be accoutable for their actios. The professioal bodies ad Royal Colleges were cocered that oce staff had filled i a icidet report they were abrogatig further resposibility for the patiet safety icidet to the recipiet of the report. As a result the Royal Colleges have begu to place greater emphasis o patiet safety i their curricula, for example the ew Moderisig Medical Careers iitiative gives much greater promiece to behaviours that are iteded to improve patiet safety. I future juior doctors will have to demostrate their competece i commuicatio ad cosultatio skills, cliical goverace ad team workig. Ad a umber of uiversities are curretly pilotig patiet safety modules i their medical udergraduate degree courses. The professioal regulatory bodies have also bee strogly emphasisig the idividual resposibility of cliicias for patiet safety through their Fitess to Practise schemes This emphasis may be payig divideds as 93 per cet of directors of patiet safety reported that relevat staff groups played a role i idetifyig patiet safety priorities ad i the desig ad developmet of solutios i their trusts. However, few trusts provide icetives for staff to improve patiet safety; oly 16 per cet told us they used icetives for maagers ad 15 per cet for cliical staff. Most trusts agreed that detailed job descriptios, staff appraisal ad 360 degree feedback exercises were the key tools for focusig staff o improvig patiet safety. A Safer Place for Patiets: Learig to improve patiet safety 17

24 part oe 1.19 The Natioal Patiet Safety Agecy has bee collaboratig with orgaisatios represetig NHS staff ad produced tools to promote awareess ad uderstadig of patiet safety (Appedix 6). Some trusts are usig the Natioal Patiet Safety Agecy s iductio video ad there are e-learig projects i the pipelie (Case example 3). Most trusts have improved their patiet safety eviromet i respose to risk maagemet requiremets 1.20 For the NHS to be safety coscious the Departmet advocated that trusts become, ad remai, aware of potetial risks so that they were i a positio to take actio to mitigate them before patiet safety icidets occur. We developed a objective measure to assess trusts relative performace with regards to reportig ad learig from patiet safety icidets based o resposes to key questios i our survey (Appedix 2) Our results showed that the majority of trusts have made substatial progress i itroducig a patiet safety focused eviromet. No trust obtaied a perfect score. Three trusts achieved a score of over 90 per cet, while two trusts achieved a score of just 33 per cet. The average score was 67 per cet. Most trusts are reactive i their approach to patiet safety, oly takig actio followig a icidet or ear miss. A few trusts have achieved the stage where maagig risk is a itegral part of everythig the orgaisatio does (Case example 4 overleaf) These fidigs are backed up by the results of trusts self-assessmet agaist the Risk Maagemet System Cotrols Assurace Stadard (oe of 22 stadards that formed part of the NHS Cotrols Assurace project). Te per cet of chief executives raked this as the biggest driver for their board to improve patiet safety. Trusts had to udertake self-assessmet agaist criteria such as board accoutability, adverse icidet reportig ad complaits ad claims hadlig. Durig the years it was i operatio the assurace scores for acute, ambulace ad metal health trusts rose from a average compliace of 52 per cet i to 87 per cet i , showig that trusts are gradually movig towards a comprehesive risk maagemet process. Case Example 3 Ivolvig Doctors with the Patiet Safety Ageda Situatio: Doctors.et.uk was set up i 1998 to facilitate commuicatio betwee doctors ad to provide liks to policies ad guidace for all specialties. Eighty per cet of all registered doctors i the Uited Kigdom, from all specialties withi the health sector, are members. Doctors.et.uk offers olie learig modules which ca cout towards doctors persoal developmet plas ad it idetified that juior doctors startig hospital placemets could beefit greatly from additioal traiig to reduce the risks to the safety of their patiets. Actio: It commissioed 24 modules, uder the title of the Cliical Foudatio Programme, directly related to specific areas of juior doctors resposibilities, such as Abormal blood results (ad what to do), Drugs dosage ad admiistratio, Good medical records ad Is your hospital safe? The Medical Protectio Society sposored the programme, offerig a 50 per cet discout o joiig fees for those juior doctors who passed te of the modules. Although maily aimed at house officers it is available for seior house officers as well. The programme commeced i August 2003, with two modules lauched each moth ad all accredited modules were available by July Outcome: There has bee a high uptake of the programme by juior doctors. Betwee August 2003 ad July 2004, 4,671 doctors passed 10,780 modules ad almost 3,000 others bega at least oe module. The most popular topics were Work life balace ad Basic blood gas aalysis. Give the positive respose, there will be further modules offered relatig to patiet safety icidets ad reportig ad learig lessos from them. The Natioal Patiet Safety Agecy commissioed this work ad it will revolve aroud a patiet safety icidet sceario. Source: Natioal Audit Office 1.23 From iceptio i 2000, the eight criteria cotaied i the Risk Maagemet System stadard were the same as those used by the NHS Litigatio Authority for the purposes of the Risk Poolig Schemes for Trusts. Idepedet assessors, workig o behalf of the NHS Litigatio Authority to evaluate cliical ad o-cliical risk maagemet uder the Cliical Negligece Scheme for Trusts ad Risk Poolig Schemes for Trusts, foud that year o year trusts have cotiued to improve their compliace with the assessmet criteria. Twety-six per cet of chief executives raked NHS Litigatio Authority stadards ad evaluatios as the chief driver for their board to improve patiet safety because the higher their effectiveess ratig ad level of compliace with the stadards, the greater the discout o their cotributios to the Schemes (oe trust has maaged to reduce its cotributios by 750,000). 18 A Safer Place for Patiets: Learig to improve patiet safety

25 part oe Figure 4 shows the ratigs for acute ad metal health trusts for as compared with (a specific ambulace assessmet was itroduced i ad so comparatives have ot bee icluded) ad Appedix 7 gives details of the assessmet criteria From April 2005, all trusts ad other providers of NHS healthcare were expected to comply with a ew performace framework. Stadards for Better Health provides a commo set of requiremets to esure that health services are safe ad of acceptable quality; ad a framework for cotiuous improvemet i the overall quality of care that people receive. The Healthcare Commissio has resposibility for assessig trusts performace agaist seve domais with both core (where compliace is ot optioal) ad developmetal stadards. The first domai is Safety (Appedix 7) As with Cotrols Assurace, the ous is o healthcare orgaisatios to esure that they are meetig the expected stadards of performace. O 31 October 2005, trust boards will make a draft declaratio o the extet to which they are meetig the core stadards; idetifyig areas where they are at risk of ot meetig them; ad ay actio they propose to take to address the risks. They will supplemet this with commets from their patiet ad public ivolvemet forum, local overview ad scrutiy committee ad strategic health authority. The Healthcare Commissio will check these declaratios agaist a wide rage of surveillace iformatio ad follow up were there are cocers. I subsequet years trusts will be expected to make a declaratio o performace agaist both the core ad developmetal stadards. 4 NHS Litigatio Authority Year Ed Assessmet Results for ad For the first time sice iceptio of the Scheme, all 239 NHS hospital (acute ad metal health) trusts have achieved at least Level 1 of the Cliical Negligece Scheme for Trusts geeral assessmet ad oly oe had yet to reach Level 1 for the Risk Poolig Schemes for Trusts. Hospital Trusts cliical Negligece Scheme for Trusts Geeral risk Poolig Scheme for Trusts Level 0 Level 1 Level 2 Level 3 Level 0 Level 1 Ed of % 74% 22% 4% 0.4% 99.6% Ed of % 74% 19% 2% 15% 85% Source: NHS Litigatio Authority A Safer Place for Patiets: Learig to improve patiet safety 19

26 part oe case example 4 Timelie for Chesterfield Royal Hospital NHS Foudatio Trust Joied the Cliical Negligece Scheme for Trusts (CNST) ad started work o improvig patiet safety ad becomig a leader i the field. Set up Cliical Risk Group. It receives mothly cliical icidet reports, discusses trust-wide implicatios, makes recommedatios ad cosiders educatioal requiremets. Itroduced the cetral cliical equipmet library to esure better maagemet of equipmet ad improve patiet safety. Workig database established to esure all equipmet complied with required stadards. Preseted opportuity to start stadardisig devices to reduce the possibility of staff usig equipmet with which they were ufamiliar. All ew cliical procedures discussed with patiet safety team. Jauary Achieved CNST Level 1 Autum First trust to reach CNST Level 2 First patiet safety advisor appoited Cliical Goverace Committee, a subgroup of the Trust Board, is set up Head of patiet safety team starts sharig examples of good practice with other trusts who cotacted her. Trust board issued their statemet o risk maagemet ad reportig icidets i all payslips. This statemet is issued aually: the view of the board is that discipliary actio should ot form part of the respose to a report of a icidet. However, it is importat staff are aware this may ot be possible i cases where Madatory iductio traiig itroduced. It outlies the Trust s risk maagemet strategy. All traiig programmes, icludig updates, cover fillig i a patiet safety icidet form, explai the gradig of icidets ad have examples of adverse cliical evets. Emphasis placed o fair blame culture ad lessos leart. Head of the patiet safety team appoited ad the Director of Nursig was give executive board resposibility. They were the key drivers i brigig patiet safety to the forefrot. Head of patiet safety starts meetigs with ew cosultats to outlie the Trust s policy for patiet safety reportig ad their fair-blame culture. Itroduced risk remiders leaflet which icludes examples about specific topics, such as reportig faulty equipmet ad completig blood samples request forms correctly, ad importat issues arisig from treds i reported icidets. Source: Natioal Audit Office 20 A Safer Place for Patiets: Learig to improve patiet safety

27 part oe A subgroup of the Cliical Risk Group is set up to review each feature of CNST stadards ad to esure speciality/directorate actio plas are developed ad delivered. Members also carry out a cliical risk assessmet of their speciality/ directorate with a patiet safety advisor. First iteral risk assessmet carried out by each directorate to idetify ad maage risk. Icrease i icidets due to delay i the review of radiological reports. A ivestigatio was carried out by the patiet safety team ad the imagig maager which resulted i a ew set of procedures to evidece that imagig reports had bee reviewed. A bechmarkig audit followed to esure this ew procedure was beig complied with. It will be repeated agai i six moths. Secod patiet safety advisor appoited Cliical claims hadler appoited. Jauary - April Piloted e-form. Third patiet safety advisor appoited Weekly icidet review meetigs commeced atteded by matros of all directorates, members from the patiet safety team ad allied health professioals to talk through ay patiet safety issues. The group discusses progress o outstadig actios ad raises ay issues from ew icidets durig the last week. It is also a opportuity for members to share ew ideas ad solutios from their directorates/specialities, cascade iformatio from audits triggered by icidets ad bulletis. Jue Chesterfield Trust the first to reach CNST Level 3 i both geeral ad materity services. Itroduced iteral cliical alerts to highlight very serious issues. A alert based o blood trasfusio policies was produced after a sigificat ear miss. A Safer Place for Patiets: Learig to improve patiet safety 21

28 part two Part two Local reportig has improved but there have bee delays i establishig a effective atioal system 22 A Safer Place for Patiets: Learig to improve patiet safety

29 part two 2.1 If you ca t measure it, you ca t maage it is a key message for patiet safety. A orgaisatio with a memory 1 idetified a lack of robust comprehesive iformatio as the reaso why the NHS was failig to lear the lessos of past evets. It preseted the first atioal estimates of the umber of icidets of uiteded harm, estimatig that oe i te admitted patiets experieced some form of harm, costig the NHS 2 billio. To this must be added approximately 430 millio paid out each year i settlemet of cliical egligece claims ad the 1 billio cost of hospital acquired ifectio 19. Estimates suggest aroud half of these icidets could have bee preveted 2. The Departmet s respose, Buildig a safer NHS for patiets 3, detailed plas to establish uified mechaisms for reportig ad aalysig iformatio o errors ad the eed to agree defiitios. 2.2 This Part of the report examies the capacity of trusts to collect iformatio locally o patiet safety icidets ad their ability to idetify patters ad treds. We also assessed the NHS s progress agaist the objectives ad targets set out i Buildig a safer NHS for patiets 3, icludig the implemetatio of a atioal reportig system for learig ad the progress agaist the targets to reduce four specific high risk or frequetly occurrig types of icidets. All trusts have orgaisatio-wide patiet safety reportig systems 2.3 Research o the characteristics of effective local icidet reportig systems suggests that they should ideally be itegrated, cofidetial ad collect iformatio o icidet severity ad risk. Our survey showed that 97 per cet of trusts operate a reportig system that records both cliical ad o-cliical icidets. I 2004, 63 per cet of trusts had a cofidetial icidet reportig system ad 36 per cet had a ope reportig system. By 2005, may more trusts had moved to ope reportig systems (34 per cet had a cofidetial system ad 63 per cet a ope system). I additio 38 per cet of trusts had facilities to eable staff to report cocers through a aoymous reportig route, such as a whistle-blowig hotlie, or for specific icidets such as medicatio errors. The total umber of icidets reported has rise year o year 2.4 Fifty-six per cet of trusts told us that reportig of icidets was much more commo amogst their staff, followig a slow ad steady developmet of a patiet safety culture. A few trusts had made the reportig of icidets madatory with a discipliary procedure if a member of staff had witessed a icidet but ot reported it. I the Natioal NHS Staff Survey , 85 per cet of staff said their employer ecouraged reportig of errors, ear misses ad icidets. A Safer Place for Patiets: Learig to improve patiet safety 23

30 part two 2.5 As expected, the umber of icidets reported aually to trusts icidet reportig systems has icreased, which suggests that most trusts have made progress i creatig a culture i which staff are prepared to report (78 per cet of trusts told us that their ecouragemet of staff to report had had a positive impact o the umber of icidets reported). 2.6 I respose to our 2004 survey, trusts reported that i they had recorded some 885,832 icidets ad ear misses (data provided by 256 trusts). I our 2005 re-survey, data from 212 trusts idicated that for , 758,528 icidets ad ear misses were recorded (the average (media) icrease reported by trusts was four per cet suggestig that the total umber of reported icidets ad ear misses i is likely to be aroud 973,560). A year o year compariso of icidets is difficult as may trusts have chaged their systems ad therefore were oly able to provide full data for the last two years. Nevertheless, a aalysis of the average umber of icidets per 1,000 staff shows that sice the umber of reported icidets ad ears misses has icreased by 24 per cet (Figure 5). The Departmet told us that it welcomed this icrease i umbers as it showed a more complete coverage of reports from across the NHS. 2.7 The icrease i reported icidets across the NHS is also demostrated by comparig the media umber of reported icidets per trust over the last three years (1,954 i , 2,511 i , 2,946 i ad 3,184 i ). Nevertheless, there are still wide variatios i the umber of reported icidets per type of trust (Figure 6). 5 Number of reported icidets ad ear misses per 1,000 members of staff i each reportig year by type of trust The umber of icidets reported per 1,000 members of staff has icreased year o year i all types of NHS trust. Trust type Acute 950 1,099 1,165 1,216 Ambulace * * Metal Health * 1,629 1,744 1,610 All trusts 1,000 1,148 1,190 1,201 Percetage icrease sice Total umber of icidets reported 447,228 icidets 707,509 icidets 885,832 icidets 758,528 icidets (175 trusts) (225 trusts) (256 trusts) (212) or 973,560 if extrapolated to 256 trusts Source: Natioal Audit Office survey of 267 NHS acute, ambulace ad metal health trusts 2004 ad Natioal Audit Office update survey of 211 acute, ambulace ad metal health trusts 2005 with results extrapolated to the same trust that respoded i 2004 Note * idicates isufficiet resposes to make comparisos. 24 A Safer Place for Patiets: Learig to improve patiet safety

31 part two 6 Number of icidets ad ear-misses reported There is a wide variatio i reported icidets ad ear misses both betwee similar NHS trusts ad the differet types of trusts. Ambulace trusts, give the ature of their role, have sigificatly fewer icidets reported tha either metal health or acute trusts. Number of icidets ( ) (000s) Acute Ambulace Metal Health Trust Type Source: Natioal Audit Office survey of NHS acute, ambulace ad metal health trusts 2004 (resposes from 256 trusts) Number of icidets ( ) (000s) Acute Ambulace Metal Health Trust Type Source: Natioal Audit Office re-survey of NHS acute, ambulace ad metal health trusts 2005 (resposes from 212 trusts) NOTES : Reported icidets i acute trusts raged from 94 to 16,186; i ambulace trusts from 6 to 770 ad metal health trusts 4 to 9, : Reported icidets i acute trusts raged from 134 to 13,056; i ambulace trusts from 15 to 825 ad metal health trusts 81 to 8,472. A Safer Place for Patiets: Learig to improve patiet safety 25

32 part two 2.8 The Natioal Patiet Safety Agecy suggests that over time it would expect the total umber of reported icidets to icrease to facilitate learig but the umber of severe icidets should declie. Most trusts bega to use the Natioal Patiet Safety Agecy defiitios of severity i I our 2004 survey, oly 22 per cet of trusts were able to provide us with iformatio o severity for all their reported icidets whereas i our 2005 re-survey of icidets i , this had icreased to 35 per cet of trusts. Give the emphasis o ecouragig reportig, to date the umbers of all types of reported icidets are icreasig (Figure 7). I our survey those trusts that graded icidets reported that they had records of 2,181 death icidets for the year eded March 2005 (90 per cet of trusts graded icidets by severity ad 58 per cet of trusts graded icidets usig severity, likelihood of recurrece ad likely cosequeces of recurrece). 2.9 Retrospective studies of hospital case records i coutries such as the Uited States ad Australia have show a substatial rate of adverse evets (Appedix 4). I Eglad, there is limited atioal iformatio o the severity ad outcome of adverse patiet safety icidets ad published estimates vary widely. I 1999 a retrospective review 2 of 1,014 medical ad ursig records from two acute hospitals i Lodo foud that 110 (10.8 per cet) of patiets experieced a adverse evet, about half of which were judged to have bee prevetable with ordiary stadards of care. A third of these evets were judged to have led to moderate impairmet (19 per cet) or permaet impairmet (6 per cet) or death (8 per cet). These adverse icidets resulted i some 999 extra bed days of which 460 were judged to be prevetable, ad which would have saved the two trusts 290,268 i direct costs. 7 Number of icidets reported compared to severity To date reported icidets i all categories are icreasig. Total umber reported (000s) Total No harm ad low Moderate Severe harm ad death NOTE Based o resposes from the 58 trusts that were able to provide us with data o umbers of icidet by grade for each year. Source: Natioal Audit Office survey of NHS acute, ambulace ad metal health trusts A Safer Place for Patiets: Learig to improve patiet safety

33 part two 2.10 The above pilot study is widely quoted as providig the best iformatio curretly available o patiet outcomes as a result of adverse patiet safety evets. Sice the various publicatios o patiet safety have applied the fidigs to derive a atioal figure for deaths ad permaet disabilities. For example i 2001, the Departmet s draft guidace Doig Less Harm suggested that patiet safety icidets may have cotributed to as may as 25,000 permaet disabilities ad 34,000 deaths each year ad, i Seve steps to patiet safety 11, which superceded Doig Less Harm, the Natioal Patiet Safety Agecy estimated that there may be as may as 72,000 icidets which may have cotributed to the death of patiets, although it was uclear what proportio of this umber would die as a direct result of the icidet Improvemets i trusts reportig systems meas that more exact figures of the umber of actual reported deaths due to patiet safety icidets is ow begiig to emerge. The Natioal Patiet Safety Agecy s first Patiet Safety Observatory report i July reported that betwee December 2004 ad March 2005, the Natioal Patiet Safety Agecy received some 79,220 reports of patiet safety icidets from acute, ambulace ad metal health trusts g (a further 6,122 icidets were reported by primary care trusts makig a total of 85,342 patiet safety icidets reported to the Natioal Reportig ad Learig System up to March 2005), of which 68 per cet resulted i o harm to patiets. It estimated, based o 46 deaths reported by 18 trusts over a three moths period, that there would have bee some 840 deaths as a result of a patiet safety icidet i acute hospitals i Eglad. We foud that deaths ad serious harm are likely to be uder reported, suggestig that further work is eeded to arrive at a more precise figure. The extet of the reportig of ear misses is much lower tha expected 2.12 Some trusts did ot distiguish betwee ear misses ad icidets but our survey results revealed that although the reportig of ear misses had icreased aually, there are still far fewer ear misses reported tha icidets (the total umber i was 115,820). I , oly 52 per cet of trusts reported more tha 100 ear misses; this had icreased to 73 per cet (out of 161 who did distiguish betwee icidets ad ear misses) i The ratio of icidets to ear misses reported is useful i assessig how far a orgaisatio has developed a robust reportig culture. There is a lot of variatio betwee trusts, with betwee four ad te times more icidets reported tha ear misses; for acute trusts the ratio is 5:1, for ambulace trusts 1.5:1 ad for metal health trusts 11:1. A orgaisatio with a memory 1 stated that the health of a reportig system ca be judged by the proportio of mior icidets reported to more serious icidets reported; suggestig that for every serious accidet there will be 29 mior accidets ad 300 occasios whe the accidet could have happeed but for some reaso was averted h. Statistical aalysis also showed that the more that staff believe that their icidet reportig system is fair, the closer the ratio of icidets to ear misses Some trusts have developed a Close-Call reportig system, separate from the mai icidet reportig system, to capture iformatio o situatios that could have resulted i a accidet, ijury or illess but did ot, due to chace or timely itervetio. All reporters are guarateed aoymity ad forms typically take fewer tha five miutes to complete. Although this has maximised the trusts opportuities for learig from ear misses to improve patiet safety, it does mea that these icidets may ot be fully recorded i the trusts icidet reportig system ad cosequetly i the atioal collatio of icidets. Uder-reportig persists to varyig degrees betwee staff groups ad trusts 2.15 Thirty-five per cet of executive directors of patiet safety told us that uder-reportig of patiet safety icidets was a moderate problem, with two per cet statig it was a major problem for their trust. Most (93 per cet) trusts had attempted to estimate the proportio of icidets ad ear misses reported ad they told us that o average aroud 22 per cet of icidets wet ureported ad 39 per cet of ear misses (Figure 8). Similarly, i the Natioal NHS Staff Survey , healthcare workers said of those patiet safety icidets they had witessed, someoe reported it i 83 per cet of cases. g h The total should icrease as the umber of orgaisatios that report icreases, as staff sed reports direct to the Natioal Reportig ad Learig System ad more importatly, as a ope culture becomes more wide spread withi orgaisatios so that more staff feel able to report icidets. Heirich, whe ivestigatig factory accidets i the 1940s idetified this 1:29: 300 ratio. A Safer Place for Patiets: Learig to improve patiet safety 27

34 part two 8 NHS trusts best estimates of the proportio of actual icidets ad ear misses which go ureported Staff are more likely to report actual icidets tha ear misses. Actual icidets 1 that go ureported 36% 11% 0% 1% 52% 2.16 Research idicates that certai types of icidet are more likely to be uder-reported. I our visits to trusts, maagers poited out that staff were less fearful about reportig a patiet fall, as i may cases the attributed cause was ot direct staff actio. I cotrast, medicatio errors ad adverse drug reactios were uder-reported due to fears of repercussios ad these icidets were ofte complex ad multi-factorial i ature (a fact that is supported by research fidigs). Also staff o wards suggested that, as uder-reportig of medicatio errors was a ackowledged problem, oe solutio might be to have a aoymous reportig system for drug related icidets. Ideed, i a umber of trusts staff ca report direct to the pharmacy or there is aoymous reportig for drug related icidets i additio to the trust-wide icidet reportig system (Illustrative example 2). Whilst this goes agaist the premise of a ope reportig culture, it does allows maagers to respod to recurret problems. Near misses 2 that go ureported 2% 14% 24% 2.17 Sevety-seve per cet of trusts told us that uderreportig by medical staff was a problem, whereas oly eleve per cet believed uder-reportig was a problem amogst urses. Executive directors of patiet safety cosidered that this was partly due to doctors expectig the urse to report the error. Key: estimated proportio of icidets ad ear misses that go ureported 0-20% 21-40% 41-60% 61-80% % Source: Natioal Audit Office survey of NHS acute, ambulace ad metal health Trusts 2005 NOTES 30% 1 Based o 201 trusts. 2 Based o 198 trusts. 30% 2.18 I a Doctors.et.uk survey of 3,314 doctors workig i secodary care 20, 78 per cet ackowledged that they had made a mistake which had a impact o patiet care, but oly 19 per cet said that they had reported a error through the trust or the Geeral Medical Coucil. Just 17 per cet stated that most ofte they would report through those systems. Niety-seve per cet of respodets agreed that a system, which was ot operated by either trusts or a Departmetal orgaisatio, as for example happes i the rail ad aviatio idustries (Appedix 3), which allowed them to report electroically ad receive feedback aoymously, would ecourage reportig. However, this would segregate a key staff group ad udermie moves towards a ope ad fair reportig culture. Some trusts we visited had achieved high levels of icidet reportig amogst doctors by allowig them to report i differet ways, (with the iformatio beig fed ito the mai reportig system at a later date); providig feedback o every report ad promotig awareess of the ope ad fair culture. Case example 5 illustrates a atioal iitiative to improve reportig by doctors. 28 A Safer Place for Patiets: Learig to improve patiet safety

35 part two Illustrative example 2 Usig aoymous reportig systems for medicatio errors I 1993 Kig s College Hospital established a aoymous medicatio error reportig scheme called Sure-Med. Prior to this Pharmacy had little kowledge of the types or umbers of medicatio errors occurrig i the trust. Errors idetified were reported to Pharmacy via a specific telephoe lie i the Medicies Iformatio Departmet. Reports were reviewed by a multidiscipliary group who issued alerts ad ewsletters highlightig problem drugs or practices. Durig the first year the reportig rate averaged betwee 30 ad 50 errors per quarter. By 2001 Pharmacy had reviewed over 600 reported medicatio errors allowig themes ad treds to be idetified ad iformatio to prevet recurrece of commo errors to be dissemiated to staff. Source: Natioal Audit Office survey of acute, ambulace ad metal health trusts Staff ofte cite fear of reprisal as a barrier to reportig but there are may other factors which discourage healthcare workers from reportig patiet safety icidets. Our fidigs i our report o cliical goverace 4 idetified that some of the most sigificat barriers to icidet reportig were culture (56 per cet), lack of resources (23 per cet) ad problems with iformatio (14 per cet trusts). These were very similar to the resposes to our survey i 2004 (Figure 9 overleaf). Almost all ew staff receive traiig o icidet reportig, but it is less likely to be give to existig employees, temporary staff ad cotractors 2.20 Most trusts maitaied staff awareess of the eed to report through at least oe method such as update traiig ad staff commuicatio ad appraisal systems. Educatio ad traiig is essetial if staff are to be ecouraged to report ad we foud that 97 per cet of trusts traied ew employees o what, whe ad how to report. However, there were less comprehesive methods for makig temporary staff ad cotractors aware of patiet safety reportig requiremets (Figure 10). Trusts idetified a umber of barriers to traiig together with solutios aimed at improvig matters (Figure 11). Case Example 5 The Natioal Patiet Safety Agecy ad Doctors.et.uk Situatio: There is a perceptio withi the Health Service that doctors are less likely to report a patiet safety icidet tha, for example, a urse. Actio: The Natioal Patiet Safety Agecy has tried to target awareess of the patiet safety ageda ad it commissioed Doctors.et.uk. to commuicate electroically with their members. For example, aaesthetists ad surgeos received a lik to the Correct Site Surgery safety alert ad further iformatio o the Natioal Patiet Safety Agecy website. Doctors.et.uk also coducted a survey of juior doctors regardig the reasos why they might ot report a patiet safety icidet ad to assess their kowledge ad awareess of the Natioal Patiet Safety Agecy. Two hudred ad iety-two juior doctors replied ad the mai reasos give for choosig ot to report a patiet safety icidet were: do t have time ; do t thik it will make a differece ; ad do t believe I will get ay feedback. Also 72 per cet were udecided as to whether the Natioal Patiet Safety Agecy would improve patiet safety. Outcome: The Natioal Patiet Safety Agecy plaed a campaig to address the issues idetified ad Professor Joh Lilleyma asked for juior doctors assistace with reportig. Doctors.et.uk foud i a follow-up survey of 189 doctors that the percetage of juior doctors who thought that the Natioal Patiet Safety Agecy would improve patiet safety had icreased from 13 per cet to 34 per cet as a result of the olie iformatio campaig. The percetage of doctors idicatig that they would defiitely or be likely to use the Natioal Patiet Safety Agecy s aoymous olie reportig form icreased from 36 per cet to 48 per cet of the sample. Source: Natioal Audit Office A Safer Place for Patiets: Learig to improve patiet safety 29

36 part two 9 Most frequetly reported barriers to icidet reportig The top five reasos give by trusts for uder-reportig by staff were fear (19 per cet), poorly desiged forms (15 per cet), lack of uderstadig about what to report (13 per cet), failure to recogise that a icidet eeded reportig (eleve per cet) ad beig too busy ad lack of feedback after a report (both te per cet). STOP STOP STOP I do t kow where the forms are kept The forms are too complex for me to fill i I eed some help with iputtig this Submits copy of form to risk maagemet Eters ito risk maagemet system STOP I just do t have the resources to aalyse Icidet occurs Decide to report Icidet Locates form Completes form Iitial evaluatio STOP I m goig to get the blame Submits copy of form to direct maager Mior Serious I m just too busy at the momet How would I kow that I eeded to report it? The patiet was t harmed so why should I report? Nobody tells me aythig eve if I report STOP I m just too busy to deal with this Feedback STOP I do t have the resources to ivestigate Feedback Icidet reviewed Iitiates root cause aalysis Feedback Source: Natioal Audit Office Feedback o extet ad subsequet actio is importat 2.21 Niety-ie per cet of trusts produced formal summarised patiet safety icidet reports for review ad actio, with 80 per cet o either a mothly or quarterly basis. Most cotaied aalysis of icidets by category (91 per cet), treds (88 per cet) ad directorate (81 per cet), though few aalysed by frequecy (63 per cet), ward (57 per cet) or specialty (52 per cet) ad eve fewer aalysed by uderlyig causes (34 per cet). Illustrative example 3 shows how oe trust s system for aalysig icidets has evolved. Although some trusts log patiet complaits, claims ad icidets oto the same risk maagemet system, few actually aalysed the iter-relatioships of these data sources to idetify ureported icidets Maagemet feedback to staff who report patiet safety icidets is also crucial i ecouragig subsequet reportig, but from our survey we foud o cosistecy of practice betwee trusts, eve allowig for the differet levels of maturity i safety culture. Half told staff how they would deal with their iitial report ad 83 per cet of trusts provided feedback after a ivestigatio of the icidet had take place. As a reportig system ad culture matures, providig idividual feedback ca become a substatial admiistrative burde ad trusts eed to target feedback at areas where there are the greatest risks. 30 A Safer Place for Patiets: Learig to improve patiet safety

37 part two 10 Makig temporary ad cotract staff aware of reportig requiremets 11 Trusts have take a variety of actios to overcome barriers to traiig There are a wide rage of methods for esurig that temporary ad cotract staff are aware of their reportig requiremets for patiet safety icidets i use, but may trusts relied o just oe method. Maagemet Cascade Traiig Barriers to traiig Releasig staff Not eough traiers Commo actios to address barriers Review of requiremets ad timig ad delivery of traiig Madatory traiig days CDRom/e-learig Review of traiig capacity, capability ad delivery Additioal resources made available Busiess case for resources Commuicatios Temporary staff Cotractors Time Review of traiig requiremets, shift patters ad delivery CDRom/Itraet/e-learig Briefigs Madatory traiig Traiig i the ward/departmet Other Methods Source: Natioal Audit Office survey of NHS acute, ambulace ad metal health trusts 2004 Source: Natioal Audit Office survey of NHS acute, ambulace ad metal health trusts 2004 NOTE Noe trusts used oly oe method for temporary staff; 70 trusts used oly oe method for cotract staff. Illustrative example 3 Tred aalysis of uderlyig causes West Middlesex Uiversity Hospital NHS Trust has bee operatig a commo trust-wide icidet reportig system that, for the past seve years, has icluded the reportig of patiet safety icidets. Staff reported the details ad uderlyig causes of the icidets cofidetially usig the Trust IR1 form. However, i respect of cliical/patiet safety icidets, ursig maagemet ad cliical leads felt that the stadard periodic reports (geerated usig the computerised icidet recordig system), whilst producig statistical iformatio, gave isufficiet isight ito the ature of the patiet safety icidets or the ways i which patiet outcomes might be improved. I 2002, the Risk Facilitator set up a database liked to the icidet recordig system. This simplified ad automated the productio of quarterly reports, detailig cliical categories (as defied by the Cliical Negligece Scheme for Trusts) agaist the reported uderlyig causes. The Trust s Seior Maagemet ad the Directorates received these stadard reports, with the Directorate Quality ad Risk Committees beig resposible for discussig the treds ad uderlyig causes i detail. Members of the Risk Maagemet Departmet team atteded these Committees to give advice ad moitor the resposes to these reports. The Quality ad Risk Committees also had to preset at the bi-mothly Trust Goverace Committee, ad more recetly, to provide a summary of actios take for the quarterly Icidets Update bulleti so that learig was dissemiated across the Trust. Source: Natioal Audit Office A Safer Place for Patiets: Learig to improve patiet safety 31

38 part two Patiet falls are more routiely reported tha medicatio errors or adverse drug reactios 2.23 All trusts have a customised taxoomy for classifyig icidets ad there was a broad cosesus amogst the differet types of trusts that we surveyed as to the types of icidets most frequetly reported. Patiet ijury, such as slips, trips ad falls beig most commo (Figure 12) Trusts ca take steps to miimise risks, but some errors ca ever be fully elimiated from healthcare (Figure 13). For example, o wards where rehabilitatio is a importat part of recovery for elderly ad vulerable patiets, it is difficult to elimiate all risk of them fallig. I cotrast, evidece idicates that automated processes reduce errors, for example computerised prescribig systems remove opportuities for documetatio error (Illustrative example 4). I 2000 A orgaisatio with a memory idetified weakesses i the plethora of icidet reportig systems used i the NHS 2.25 Traditioally exteral regulators, such as cliicias regulatory bodies ad the Royal Colleges, ad professioal bodies have ispected ad ivestigated whe there were cocers about the safety of patiets. For may years there have bee Natioal Cofidetial Equiries ito materal death, perioperative death, stillbirths ad ifat death, ad suicides ad homicide by people with metal illess. There are also a umber of log stadig, volutary reportig systems to collect data ad ecourage learig o specific types of patiet safety icidets. For example, the Adverse Icidet Reportig System for medical devices ad the Yellow Card Scheme for routie moitorig of medicies safety. 12 Frequecy of icidets by type Patiet ijuries are the most frequet types of reported patiet safety icidet. Patiet ijury, e.g. falls 31.5% Medicatio errors 7.1% Equipmet related 4.1% Poor records/ lack of documetatio 1.8% Commuicatio errors 1.6% Diagostic test errors 1.1% Lack of dedicated/ permaet staff 1.1% Self-harm 1.0% 0 50, , , , , ,000 Source: Natioal Audit Office survey of acute, ambulace ad metal health trusts 2004 NOTE Based o NHS data for Accidet ad emergecy attedaces: 16.5 millio; Fiished cosultat episodes: 13 millio; Patiet joureys by ambulaces: 18 millio. 32 A Safer Place for Patiets: Learig to improve patiet safety

39 part two 13 Perceived prevetability of patiet safety icidets Staff perceive it is easier to reduce some types of patiet safety icidets, especially if resources are limited. High frequecy Patiet falls Medicatio errors Perceived low prevetability Use of temporary staff/operatig below complemet Commuicatio failure Missig records Perceived low prevetability Adverse drug reactios Self harm Low frequecy Source: Natioal Audit Office literature review ad visits to acute, ambulace ad metal health trusts 2005 Illustrative examples 4 Usig automated processes to reduce errors Aitree Hospitals NHS Trust has piloted ad will be rollig out a automated patiet idetificatio system to reduce prescribig errors based o icorrect patiet idetificatio. The system uses a bar-coded wrist bad, with the same bar code attached to all test results ad observatio otes. The pilot proved it was a cost-savig measure for the trust. Dartford ad Gravesham NHS Trust istalled a automated dispesig robot i July 2004 as a risk reductio iitiative. The automated dispeser has helped reduce dispesig pickig errors ad so has ehaced patiet safety. The robot has also decreased dispesig turaroud times, improvig patiet throughput. As a result of the chage, the pharmacy departmet has observed a reductio i pickig errors, as well as a improvemet i the workig eviromet for dispesig staff. Other idustries successful use of simulators to teach skills that are difficult to acquire by traditioal educatioal methods ecouraged Barts ad the Lodo NHS Trust to use a cliical medicie simulator for traiig. The Trust has developed a oe-day multidiscipliary emergecy obstetric traiig course i which aaesthetists, obstetricias ad midwives use a lifelike maiki that artificially duplicates coditios without risk to patiets. Source: Natioal Audit Office survey of acute, ambulace ad metal health trusts From 1996 uder the Reportig of Ijuries, Diseases ad Dagerous Occurreces Regulatios (1995), trusts have bee statutorily obliged to report to the Health ad Safety Executive ay accidets resultig i the death, serious ijury or icapacitatio for more tha three days. Also i 1996 the four Uited Kigdom blood services fuded a scheme, established by a professioally led group kow as SHOT, to collect iformatio o serious hazards of trasfusio. Sice 1997, the Departmet has established other arm s legth orgaisatios to moitor ad review trusts performace o various aspects of patiet safety. For example, NHS Estates operated a defects ad failures reportig system (i April 2005 resposibility trasferred to the Departmet) By the time of the Chief Medical Officer s review 1 a wide rage of reportig systems were i use, but they were fragmeted ad compliace with reportig was still patchy. His report cocluded that there were several systematic weakesses i data collectio icludig: o cosesus of what to report; differet ad potetially coflictig views o the purpose of patiet safety icidet reportig systems; ad o proper likages betwee reportig systems. A Safer Place for Patiets: Learig to improve patiet safety 33

40 part two A orgaisatio with a memory proposed a sigle focal poit for iformatio o patiet safety icidets but this has ot bee achieved 2.28 A orgaisatio with a memory 1 recommeded that a direct, cofidetial, but ot aoymous, atioal reportig scheme be itroduced. Buildig a safer NHS for patiets 3 ackowledged the good work that the NHS had doe to ecourage local reportig, but idetified a eed for a madatory, atioal reportig system for patiet safety icidets ad ear misses which would be implemeted ad operated by a ew idepedet body, the Natioal Patiet Safety Agecy The aim was that the system would capture iformatio from a wide variety of sources i order to detect atioal patters, clusters or treds that could reduce risk or prevet the recurrece of icidets i the future. The Departmet recogised that i establishig the Natioal Patiet Safety Agecy to implemet ad operate the system, the same iformatio o particular patiet safety icidets would still eed to be reported to a umber of orgaisatios. Ad sice the other reportig mechaisms have also bee itroduced Give this complex reportig eviromet ad the differet maturity of systems, the Natioal Patiet Safety Agecy aimed to reduce the admiistrative burde o frot lie staff by explorig whether it could itegrate reportig of medical device icidets to the Medicies ad Healthcare products Regulatory Agecy with its ow Natioal Reportig ad Learig System. However, durig the testig ad developmet phase of the project, it became clear the Natioal Reportig ad Learig System could ot capture the detailed statutory data required by the Medicies ad Healthcare products Regulatory Agecy. As there has bee o itegratio of reportig forms, the Natioal Reportig ad Learig System added to the list of orgaisatios to which trusts were already required to report ad trusts still face a extremely complex system of reportig ad ivestigatio. Figure 14 overleaf shows the mai atioal reportig systems, but aroud 30 routes still remai. The atioal reportig scheme was rolled out two years later tha origially plaed 2.31 Buildig a safer NHS for patiets 3 proposed a ew atioal reportig system for learig ad evisaged that by December 2001, 60 per cet of trusts would be able to provide iformatio to the system ad that by the ed of 2002 all NHS trusts, ad a sigificat proportio of primary care trusts, would be providig iformatio to the system. The system was evisaged as beig: madatory for idividuals ad orgaisatios; cofidetial, but ope ad accessible; geerally blame free ad idepedet; simple to use but comprehesive i coverage ad data collectio; ad allow systems learig ad chage at local ad atioal levels. Healthcare orgaisatios i other coutries, havig compared the merits of aoymous ad cofidetial reportig, have geerally opted for cofidetial reportig (Appedix 4). Other idustries have also opted for cofidetial ad ot aoymous reportig systems (Appedix 3). Over time, as the aviatio idustry ad some hospitals i the Uited States of America have embedded their systems, they have moved towards a ope system of reportig Followig publicatio of Buildig a safer NHS for patiets 3 (ad prior to the formatio of the Natioal Patiet Safety Agecy i July 2001) the Departmet coducted a Official Joural of the Europea Commuities procuremet exercise to establish a pilot project for the atioal reportig system for learig. This resulted i the Australia Patiet Safety Foudatio beig awarded a cotract to develop software for a cetral repository ad Safecode (Uited Kigdom supplier of risk maagemet systems to trusts) beig egaged to work with the Australia Patiet Safety Foudatio to develop software to allow patiet safety icidet data (both the details of the icidet ad root cause aalysis) to be extracted from local reportig systems. The pilot commeced i September 2001 i 28 trusts; a iterim report was published i April 2002 ad a fial report i Jue A Safer Place for Patiets: Learig to improve patiet safety

41 part two 2.33 The report o the pilot cocluded that it had bee successful i idetifyig implicatios for the implemetatio of a atioal reportig system for learig across the NHS, although trusts had some difficulties capturig the root cause aalysis data. The Natioal Patiet Safety Agecy cosidered that the roll out of the pilot would be either optimal or cost effective due to the complexity of data extractio ad data mappig problems. It therefore developed a Busiess Case with optios ragig from Do Nothig to a i-house developed computerised atioal reportig ad learig system. This latter optio, with a revised, phased, implemetatio timetable betwee summer 2003 ad December 2004, was subsequetly agreed by the Departmet ad approved by the Treasury i February 2003 (subject to close scrutiy of the e-form itegratio with local risk maagemet systems ad the carryig out of peer reviews as suggested by the Office of Govermet Commerce). i 2.34 The approved optio was to collect comprehesive data o patiet safety icidets i NHS trusts ad idetify atioal treds i icidets, from which the Natioal Patiet Safety Agecy could develop practical solutios for applicatio across all local orgaisatios. The Natioal Reportig ad Learig System either extracts iformatio directly from trusts ow icidet reportig systems, which is the de-idetified, or collects iformatio from a aoymous electroic reportig form (e-form). The cost i the busiess case was 9.4 millio over seve years. As at March 2005, 5.5 millio had bee spet from a revised lifetime budget of 10.4 millio (Jue 2004) The Natioal Patiet Safety Agecy s decisio to devise a aoymous reportig e-form was based o the belief that assuraces of cofidetiality would ot be eough to ecourage cliicias too frighteed to report ad that there was a eed for a safety et. Experiece, at trusts where both aoymous ad cofidetial systems work i parallel, has showed that less tha te per cet of all reported icidets are submitted aoymously. Some trusts told us that the potetial for icidets to by-pass their ow reportig systems would i their view udermie the progress they had made i establishig a ope ad fair culture The Natioal Patiet Safety Agecy believe the iitial idicatios are that the e reportig system will be a rich source of iformatio for learig. Niety-four per cet of the 108 reports received betwee September 2004 ad March 2005 had the agreemet of the reporter to share the iformatio with the trust ivolved. Although still early, 13 per cet of reports are from medical staff who geerally may be less likely to report icidets locally Buildig a safer NHS for patiets 3 stated that the data requiremets at local ad atioal levels are differet. Trusts eed to kow who reported the icidet, to esure o misiterpretatio ad to validate the iformatio. I cotrast, atioal reportig systems gather iformatio about what, where, whe, how ad why thigs are likely to go wrog, what actio is take, the impact of the icidet ad what could have bee doe to prevet it, rather tha idetify the people ivolved. The majority of the data captured by the Natioal Reportig ad Learig System has come from local icidet reportig systems ad all trusts told us that it had already bee aalysed to idetify learig. Niety-ie per cet provided examples of such learig. Therefore the Natioal Patiet Safety Agecy could have collected aggregate iformatio o commoly occurrig icidets that trusts kew about ad used it to promulgate learig atioally, whilst focusig o the collectio of iformatio o less frequet icidets A orgaisatio with a memory 1 evisaged the atioal collectio of certai categories of data ad Buildig a safer NHS for patiets 3 that defiitios of icidets should gradually move to iteratioally agreed stadards. To meet its objective of idetifyig ad dissemiatig patiet safety learig the Natioal Patiet Safety Agecy decided ot to limit its dataset ad cosequetly the Natioal Reportig ad Learig System receives data o all icidets, regardless of their potetial for atioal learig. Ad despite the existece of well developed iteratioal icidet classificatio, the Natioal Patiet Safety Agecy decided to defie its ow taxoomy for atioal reportig ad produce tailored versios for use i ie differet healthcare settigs. However, reportig fields, which idetify the cotributory factors to the icidet, are optioal, ad compliace is variable, eve though the learig of lessos is most likely to come from this iformatio. i As the focus of study is o reportig ad learig to improve patiet safety a audit of the procuremet ad implemetatio of the Natioal Reportig ad Learig System was out-with the scope of this study the refereces herei are used to demostrate the reaso for the chages to the implemetatio timetable ad the delay i the opportuity for atioal reportig ad learig. A Safer Place for Patiets: Learig to improve patiet safety 35

42 part two 14 Orgaisatios ivolved i collectig reports o patiet safety icidets ad ear misses ad ecouragig learig from these icidets There is duplicatio i the reportig ad ivestigatio of patiet safety icidets. Trust icidet reportig system (plus close-call) Medicies ad Healthcare products Regulatory Agecy Health Protectio Agecy NHS Litigatio Authority NHS Estates 1 Natioal Patiet Safety Agecy Health ad Safety Executive ?????? G G G G G G G!!!!! Patiet ijury l l 3 l l l Adverse drug reactios l l 3 l Equipmet failure or malfuctio l l l Blood trasfusio errors l 4 3 l Commuicable disease outbreaks l l l 3 l l Suicides l 5 l Violece ad aggressio l l l l Abscosio l l Uexpected death l l 3 l Key 4 Receive reports? Coduct ivestigatios G Issue guidelies! Issue alerts l Required to be reported l Depeds o uderlyig cause ad severity Source: Natioal Audit Office NOTES 1 The Departmet has ow take over NHS Estates resposibilities for the health ad safety ad evirometal reportig. 2 Oly for patiets detaied uder the Metal Health Act. 3 Will oly receive reports, coduct ivestigatios, issue guidelies ad alerts if there is sigificat risk or a claim has bee received. 4 From November 2005 the Medicies ad Healthcare products Regulatory Agecy assumes resposibility for Haemovigilace. The ew system will provide a sigle data etry poit for Medicies ad Healthcare products Regulatory Agecy ad Serious Hazards Of Trasfusio reports. 5 Data o those icidets ivolvig licesed medicies or where a medical device is ivolved ad a device fault eeds to be ruled out. 36 A Safer Place for Patiets: Learig to improve patiet safety

43 part two Serious Hazards of Trasfusio Metal Health Act Commissioers 2 4 4? Police 4? Coroer 4? 2.39 The full roll out of the Natioal Reportig ad Learig System commeced i September 2004, early two years later tha the headlie target i Buildig a safer NHS for patiets 3 (see paragraph 2.28). By ed of December 2004, all trusts had the techology to lik to the Natioal Reportig ad Learig System but ot all had fiished mappig their data sets. The revised target for all trusts to begi sedig their data to the System was Jue By August 2005, at least 35 trusts still had ot submitted ay data to the Natioal Reportig ad Learig System. l l l 2.40 Trusts have ivested cosiderable time ad resources to develop idividual data mappig schemes i order to comply with, ad to sed data to, the Natioal Reportig ad Learig System (Appedix 5). Our survey i 2005 showed that 12 per cet of trusts had o problems i likig to the Natioal Reportig ad Learig System. Eighty-two per cet of trusts reported problems, of which 36 trusts said these were major, ad these were due to time ad resource issues (64 per cet ad 46 per cet respectively) ad software compatibility issues (39 per cet). We foud that there was a sigificat relatioship j betwee the maufacturer of the trust s icidet reportig system ad the ease with which the local ad atioal data sets were itegrated. l l l l l l l l The Departmet focused o improvig levels of reportig ad learig but evidece o progress agaist the specified high risk areas is patchy 2.41 The Departmet idetified target reductios for four specific high risk areas which, despite a body of evidece o them, had ot bee addressed satisfactorily (Figure 15). j Usig a Chi-Squared test ( X2 = 43.09, df=22, p= 0.05). A Safer Place for Patiets: Learig to improve patiet safety 37

44 part two 15 Progress o the four specific targets idetified i A orgaisatio with a memory Risk Target Date Positio at July 2005 Positio at August 2005 (Report from NHS Trusts) Fatal icidets occur if drugs are icorrectly admiistered Reduce to zero ed the umber of 2001 patiets dyig or beig paralysed by mal-admiistered spial ijectios I April 2001, the Departmet published a report o the prevetio of itrathecal medicatio errors 21 ad a report o the adverse icidet at Quee s Medical Cetre 22 which idetified serious systems failures. As a result all trusts that admiistered this form of chemotherapy were required to review their procedures ad make sure that they were fully compliat with the Natioal Guidace o the Safe Admiistratio of Itrathecal Chemotherapy by 31st December Trusts did ot achieve full compliace util summer 2003 after itervetios by the regioal Directors of Public Health, the Chief Medical Officer ad a health miister. The Departmet issued revised guidace i October 2003, which trusts fially self-reported compliace by Jauary Although o further cases of maladmiistered vicristie have bee reported i Eglad sice 2000, a atioal cacer peer review programme, which started i November 2004, foud ie out of 19 trusts reviewed by April 2005 were ot satisfactorily compliat, ad three of them had reported compliace. This peer review is to cotiue over the ext 18 moths ad the Departmet is workig with strategic health authorities to help esure that full implemetatio of guidace is maitaied. I collaboratio with the NHS Purchasig ad Supplies Agecy, the Natioal Patiet Safety Agecy, ad the Medicies ad Healthcare products Regulatory Agecy, the Departmet has set up a parallel project to idetify desig solutios to help prevet cross coectio errors durig spial ijectio procedures. Oly acute NHS trusts admiister spial ijectios. All trusts stated that there had bee o icidets of fatalities from mal-admiistered ijectios. Thirtee stated that they had put ew policies ad procedures ito place, ad other trusts had improved traiig ad guidace. High volume ad cost of cliical egligece claims agaist the NHS Reduce by 25 per cet the umber of istaces of egliget harm i the field of obstetrics ad gyaecology which result i litigatio ed 2005 Aroud 50 per cet of the NHS litigatio bill relates to claims arisig from childbirth ad achievig the target reductio of 25 per cet by 2005 could save as much as 50 millio a year. Evidece from the NHS Litigatio Authority suggests that the umber of claims otified (by year of formal otificatio) have reduced by aroud 13 per cet from 1,210 i to 1,051 i Projectig the tred across three years, to , suggests a 20 per cet reductio compared to the 25 per cet target. Despite this improvemet i relatio to claims other research suggest that there are some cocers about materity services which remai. For example, the Healthcare Commissio s ivestigatios ito materity services have revealed serious failigs i a umber of commo risk areas: risk maagemet, workig relatioships, traiig ad supervisio, the eviromet ad staff shortages. 7,8 The Natioal Patiet Safety Agecy s aalysis of reports to the Natioal Reportig ad Learig System shows treatmet icidets are most commo i obstetrics ad gyaecology. It will be developig solutios for wome kow to be at risk of materal death or serious materal morbidity where appropriate. Additioally, it will be reviewig system factors leadig to operative complicatios durig gyaecological surgery. This target predomiatly applied to acute NHS trusts. Out of the acute trusts that aswered this questio, just over half (55 per cet) could ot state that they had achieved this target. However, the mai reaso cited was that previous uder-reportig of icidets ad the ofte substatial delay betwee icidets ad the oset of litigatio made progress towards this target impossible to assess. 38 A Safer Place for Patiets: Learig to improve patiet safety

45 part two 15 Progress o the four specific targets idetified i A orgaisatio with a memory (cotiued) Risk Target Date Positio at July 2005 Positio at August 2005 (Report from NHS Trusts) Mistake admiistratio, prescribig or dispesig of drugs Reduce by 40 per cet the umber of serious errors i the use of prescribed drugs ed 2005 Prescribig medicie is the most frequet treatmet provided for patiets i the NHS (200 millio a year i hospitals aloe) but icidets of medicatio error are still seriously uderreported (paragraph 2.12). The Medicies ad Healthcare products Regulatory Agecy oly receives reports o drug error as the result of adverse reactios to the medicatio ad because of low reportig rates ad the may barriers to reportig medicatio errors, the true extet of serious errors i the use of prescribed drugs is ukow. The Chief Pharmaceutical Officer s 2004 report 23 highlighted drugs ad cliical settigs that carry particular risks ad idetified models of good practice to reduce risk i the NHS. The Natioal Patiet Safety Agecy has a programme of improvig medicatio safety that has icluded patiet safety alerts o potassium chloride ad methotrexate. The Departmet ad the Desig Coucil joitly commissioed a report 24 to produce practical recommedatios for the NHS to improve patiet safety through better procuremet ad desig of packagig for medicies ad medical devices. The Natioal Patiet Safety Agecy ad the Medicies ad Healthcare products Regulatory Agecy have bee workig with drugs maufacturers i the Uited Kigdom to improve labellig. Actio regardig this target was maily take by acute ad metal health trusts, with over 77 per cet of ambulace trusts statig that it did ot apply to them. Of those trusts that stated that this target was applicable to them, oly 20 per cet aswered that they had met this target. May trusts stated that this target was difficult to assess, ofte due to a lack of baselie data. The most commo resposes after this were that trusts were curretly i the process of puttig actio plas ito place, or that there were very few errors i the first place, makig a 40 per cet reductio difficult. Fatalities occur if evirometal risks have ot bee removed from metal health services Reduce to zero the umber of suicides by metal health ipatiets as a result of hagig from o-collapsible bed or shower curtai rails o wards March 2002 Six trusts failed to meet the deadlie but by the ed of May 2002 all trusts were reportig compliace. Overall, there has bee a substatial fall i the umber of ipatiet suicides from 195 i 2000 to 156 i 2002 (20 per cet reductio). However, the Natioal Cofidetial Iquiry ito Suicide ad Homicide by People with Metal Illess subsequetly idetified that suicides by hagig from ocollapsible rails had ot bee completely elimiated (two cases may have occurred sice 2002 but ivestigatios are still ogoig). NHS Estates issued a further alert i November 2004 but four trusts are still workig towards the replacemet of these fittigs. 10 All trusts that respoded that they had had o suicides as a result of hagig from o-collapsible rails. Te trusts stated that they curretly have work uderway to comply. Not achieved Progress made, but uclear if target will be met Achieved Source: Natioal Audit Office A Safer Place for Patiets: Learig to improve patiet safety 39

46 part three Part three Systems for aalysig ad sharig lessos leared are i place but are largely uder-used 40 A Safer Place for Patiets: Learig to improve patiet safety

47 part three 3.1 A orgaisatio with a memory 1 recogised that little systematic learig from patiet safety icidets ad service failures had take place i the NHS ad i most other coutries. Desigers, builders ad those resposible for developig cliical procedures ad protocols ca uitetioally embed pre-coditios i the NHS which ca cause harm to patiets. While huma error is ofte the most easily idetifiable elemet i may serious patiet safety icidets, it is oly part of the explaatio. More ofte tha ot the cetral issue is systemic: ot who made the error but how ad why the safety mechaisms failed ad what helped to create the coditios i which the mistake occurred. Buildig a safer NHS for patiets 3 therefore focused o the actio, both atioally ad locally, ecessary to establish a system that esures lessos from adverse evets i oe locality are leared across the whole NHS. 3.2 This Part of the report examies the actio take by NHS trusts, the Departmet ad other NHS orgaisatios to improve patiet safety through orgaisatioal learig. I particular through the use of iformatio o patiet safety icidets from ivestigatios ad other sources of data. Good foudatios have bee laid for improvig the quality ad relevace of local icidet ivestigatios All trusts ow udertake i-depth aalysis of icidets but capacity problems have limited the umber coducted 3.3 We foud 59 per cet of trusts had bee udertakig i-depth aalysis of icidets to lear lesso for at least two years, with eight per cet of those havig coducted aalysis for more tha seve years. We foud that there was o systematic patter as to how trusts determied what icidets required a detailed ivestigatio. Eighty per cet told us that they based their decisios o a umber of factors, icludig the severity of impact o the patiet, frequecy of icidet type ad potetial risk to the trust or the patiet. Our visits revealed the idiosycratic ways some trusts decide which icidets require aalysis. Oe trust told us that they assess the ooo-er factor of a icidet that is, whether a icidet is serious, potetially serious or uusual ad therefore may warrat further ivestigatio. A Safer Place for Patiets: Learig to improve patiet safety 41

48 part three 3.4 Forty per cet of trusts were followig the guidace o the eed to carry out full aalysis of all severe harm ad death category icidets. Nie trusts told us that staff reported 50 or more of this type of icidet durig ad all but two trusts had ivestigated more tha five per cet of these icidets. Oe of the reasos give for the lower umber of ivestigatios was that icidets were mis-graded to draw attetio to a mior icidet oe trust with a serious icidet hotlie told us it was used to report a doctor was missig, whe he was ot aswerig his bleep. Whilst most trusts raised the cost of i-depth ivestigatios as a deterret, few kew the actual cost. 3.5 There are wide variatios i the way that trusts have developed their capacity to coduct these ivestigatios. Whilst some trusts have as may as 17 traied staff per hudred staff members, others have o-oe traied to do i-depth aalysis. Oe explaatio for this variability is that i some trusts, a small umber of staff act as facilitators for others to coduct the ivestigatio, while i other trusts a large umber of staff are traied to carry out ivestigatios but will rarely be called upo to do so. The Natioal Patiet Safety Agecy s tools have cotributed to the improvemet i the quality of ivestigatios but more eeds to be doe to embed the cocept ad the lessos 3.6 The Natioal Patiet Safety Agecy itroduced the root cause aalysis toolkit to stregthe i-depth ivestigatios ad aid cosistecy. Trusts uptake of the toolkit was high, with 76 per cet of trusts i our 2004 survey havig actively ecouraged its use. Sixty per cet of trusts chaged their approach to i-depth ivestigatios as a result of the work of the Natioal Patiet Safety Agecy ad of those, 23 per cet cosidered that they ow have a better quality of ivestigatio ad 17 per cet had a more structured or cosistet approach to a ivestigatio. However, its use was limited i 37 per cet of trusts owig to time costraits. 3.7 Improvig trusts patiet safety stadards depeds o the quality of the recommedatios arisig from the root cause aalysis. Strategic health authorities told us that the quality of recommedatios made by trusts was still very variable. I North East Lodo they are addressig this through further programmes of traiig for preparatio of reports from i-depth ivestigatios. Staff also reported difficulties i gettig recommedatios actioed by orgaisatios outside their ow trust. 3.8 As yet the Natioal Patiet Safety Agecy does ot collect iformatio from trusts root cause aalyses. The Natioal Patiet Safety Agecy is scopig the possible optios for collectig iformatio o trusts root cause aalysis which will eable it to idetify atioal issues ad promulgate lessos leared. 3.9 Sice 2002, the Natioal Patiet Safety Agecy ad the Royal Colleges have joitly appoited eleve atioal Cliical Specialty Advisors, represetig most medical specialties. These cliicias support its work i idetifyig key patiet safety priorities withi ad across the specialties ad provide feedback to the colleges ad other orgaisatios, creatig a two-way flow of iformatio. Some Cliical Specialty Advisors have established Exteral Multi-Professioal Referece Groups, to validate work ad recommedatios, ad to udertake a holistic aalysis of the root causes of key patiet safety icidets. Their itetio is to help develop workable solutios for these icidets (Illustrative example 5). Illustrative example 5 I September 2003, the Cliical Specialty Advisor i Aaesthesia took up post o a oe-day per week secodmet to cotribute ad co-ordiate iput to the Natioal Patiet Safety Agecy about aaesthetic related issues. The Cliical Specialty Advisor recogises that there is o shortage of issues to be pursued, eve withi a specialty ackowledged to be a leader i aspects of safe practice. He has facilitated a risk assessmet exercise of the whole aaesthetic process to look at the jourey of a adult patiet udergoig elective geeral surgery, from referral by geeral practitioer to the coclusio of aaesthesia. From this work, key areas of potetial risk ad patiet harm have bee idetified, ad these will form part of the iitial ageda for the specialty referece group. Other projects of ote ivolvig the Natioal Patiet Safety Agecy i aaesthesia are: the productio of a report o Blocked Aaesthetic Tubig ad the subsequet revisio of the Associatio of Aaesthetists aaesthetic machie checklist, followig the tragic accidetal death of a child whe a aaesthetic circuit became blocked; efforts to desig out the risks of iadvertet spial ijectios; ad work with maufacturers ad cliicias to reduce the mis admiistratio of drugs through colour-coded labellig of ampoules ad their boxes. Source: Natioal Audit Office 42 A Safer Place for Patiets: Learig to improve patiet safety

49 part three Trusts have idetified ad implemeted lessos from icidets but few kew of the cost effectiveess of the itervetios 3.10 I their resposes to our survey, all but three trusts provided at least oe example of a lesso leart or a chage i practice itroduced followig a patiet safety icidet. The lessos or chages were mostly derived from icidet reports or a aalysis of uderlyig causes of a icidet. I some trusts, complaits ad claims were logged o the same system as patiet safety icidets which eabled them to obtai a more complete picture of errors ad ehaced their capacity to lear (Figure 16 overleaf) We foud trusts do ot routiely produce cost data o the impact of icidets or evaluatios of the chages made to processes or the eviromet. Oly three trusts had evaluated the costs icurred as a result of all icidets. The figures estimated rage from 88,000 to 400,000 per year. Six trusts calculated the cost of specific patiet safety icidets (for example, a fractured eck of femur due to a hospital-based fall costs 10,000 ad iadequate patiet iformatio or cliical details o diagostic requests costs approximately 1 millio per year). Fourtee trusts have udertake aalysis of savigs made by chages to improve patiet safety, though oly three icluded the ivestmet costs (Case examples 6 below ad 7 o page 46). Case Example 6 The Royal Marsde NHS Foudatio Trust Situatio: May patiets at the Royal Marsde require irradiated blood ad blood products to prevet Trasfusio Associated Graft Versus Host Disease, a serious ad ofte fatal disease that occurs whe there are histocompatibility differeces betwee doated cells ad the recipiets cells, usually associated with boe marrow trasplat. Trasfusio Associated Graft Versus Host Disease has a high mortality rate ( per cet). To esure quality cotrol, the Natioal Blood Service irradiates blood products for healthcare providers usig dedicated equipmet. There is a premium charge for each bag of blood, platelets or white cells irradiated (curretly 6.39 per bag). Util 2001, the Trust ordered both irradiated ad o-irradiated blood ad blood products ad the followig checks were i place to esure that patiets who required irradiated blood were give it: traiig i safe blood trasfusio practice was give to all ew urses ad doctors comig to the Trust; the Blood Trasfusio policy was posted o the hospital itraet ad available to all urses, doctors ad cliical staff; a quick referece guide for the busy cliicia detailig which patiets must receive irradiated blood products was prited o the back of the blood cross match; the Royal Marsde Maual of Cliical Nursig procedures cotaied evidece ad iformatio o Trasfusio Associated Graft Versus Host Disease; ad Radsure labels that chage colour followig irradiatio were used o blood products. Despite these checks, i 2001, a patiet i the Itesive Therapy Uit who had recetly had a boe marrow trasplat received a trasfusio with o-irradiated platelets, ad died a few weeks later. Actio: A i-depth ivestigatio ito this serious icidet foud the causes were multi-factorial. At the Natioal Blood Service, a ew techicia was preparig the platelets ad a power-cut occurred iterruptig the processig, causig o-irradiated blood to be set to the Royal Marsde. At the Royal Marsde, a ew techicia i the laboratory was uder cosiderable time-pressure ad istead of puttig the platelets to oe side whe they arrived, she placed them i the agitator ad carried o with aother task. I the Itesive Therapy Uit the staff urse was very busy so the sister o call for the hospital offered to get the platelets for her. Although the sister had had some blood trasfusio traiig ad would have bee familiar of irradiated products, she worked i a o-haematology area. Seeig the blood techicia was busy, the sister verified that the platelets were for the correct patiet ad took them up to the Itesive Therapy Uit. After checkig with the staff urse, the patiet was give the trasfusio. The patiet i questio was expected to have died despite the icidet, however it was decided durig the ivestigatio that as so may patiets at the Sutto site of the Trust require trasfusios, risks of further icidets should be reduced by the purchase of oly irradiated blood products. A busiess case to justify the extra costs ivolved was put to the Trust Board (with the support of the Cliical Goverace Executive Committee). Though the reasos behid the proposal were to esure patiet safety, the busiess case also put forward a ecoomic argumet for the purchasig of oly irradiated blood products. Trasfusio Associated Graft Versus Host Disease does ot cause immediate death but a slow (up to three weeks), paiful ad therefore costly oe as the patiet will have to be cared for i a Itesive Therapy Uit bed, costig aroud 52,000. Hece, the Trust Board deemed that the extra costs of the Sutto site purchasig all irradiated blood was good value, as well as a essetial patiet safety measure, ad thus approved the proposal. Outcome: The Trust has bee purchasig oly irradiated blood ad blood products for the Sutto site for over three years ad there have bee o further icidets of Trasfusio Associated Graft Versus Host Disease. Source: Natioal Audit Office A Safer Place for Patiets: Learig to improve patiet safety 43

50 part three 16 Trusts examples of lessos leart as a result of i-depth ivestigatios of patiet safety icidets, tred aalysis, complaits ad claims ad atioal recommedatios The top five areas for trusts to focus improvemets o were problems with equipmet (87 examples); medicatio errors (65 examples), patiet falls (48 examples), poor records ad lack of documetatio (36 examples) ad self-harm (34 examples). the royal liverpool ad Broadgree uiversity hospitals issue: The quality of the hospital case otes was havig a impact o the delivery of care due to poor presetatio, cotet ad maiteace of files. idetified via: Poor availability of case otes durig patiet cosultatio was idetified through reported icidets ad patiet complaits ad claims. actio: The Trust formed a case ote committee with represetatives from a wide rage of occupatios. A ew case-ote folder with 4 sectios ad a see-through plastic documet slot o the frot was itroduced: frot trackig remider ad istructios sectio 1 orage: all correspodece, icludig iterim discharge otes ad summaries, with the most recet letter uppermost sectio 2 gree: referral letter ad cliical medical otes i chroological order, divided ito specialties, ad pik: coset forms ad do ot attempt resuscitatio cards sectio 3 blue: results of all ivestigatios, divided accordig to specialty sectio 4 grey: the remaiig otes ad yellow: therapy records. The outer-cover was desiged to have colour coded margis for the beefit of staff filig the records. The Medical Records Maagers made presetatios to Trust staff to educate them about the ew system. The Trust fiaced the itroductio of computer scaig to replace the microfichig of case otes. A three moth supply was ordered ad followig the lauch of the system the committee cotiued to gather commets from staff so that the system ca be adjusted as ecessary. The hospital is also improvig the quality of existig records by refurbishig ad replacig old case ote folders. moorfields eye hospital hs foudatio trust descriptio of the problem Staff reported falls by patiets i outpatiet cliics. Tred aalysis revealed that there was a high level of low cosequece icidets. how the problem was addressed Staff were made aware of how to miimise the potetial for slips ad falls by elderly patiets. The Board made a oe-off ivestmet of 15,000 to replace all patiet stools i waitig areas with chairs with arms ad back support. outcome of actios take The risk of recurrece has bee sigificatly reduced. There were o patiet falls from stools withi outpatiet cliics i the eight moths after the chairs were itroduced. A cost beefit aalysis of the replacemet furiture revealed log term savigs o the cost of claims as the result of patiet falls. outcome: Staff feel case otes easier to use as the presetatio of iformatio has improved ad there has bee a reductio i the umber of bulky records. Retrieval has bee improved through the use of scaed otes. The case ote committee will be lookig at filig ad re-housig case otes i the future. Source: Natioal Audit Office Survey of Acute, Ambulace ad MH Trusts, 2004 NOTE Two hudred ad sixty-four trusts submitted a total of 749 examples of lessos leared. 44 A SAfER PLACE for PATIENTS: LEARNING TO IMPROvE PATIENT SAfETY

51 part three liverpools wome s hospital westcoutry ambulace Services descriptio of the problem: A adverse icidet ivolvig the icorrect use of a First Respose Emergecy Defibrillator was reported i accordace with the Trust s policy. There was o adverse effect o the outcome for the patiet. how the problem was foud: Followig submissio of a adverse icidet a thorough ad i depth ivestigatio took place ad the fidigs preseted to a Serious Utoward Icidet Pael. The ivestigatio idetified that, although the employee had received traiig i the use of defibrillators, he had ot bee traied i the use of the specific defibrillator i questio. The Pael cosidered the Trust s strategies, systems, processes, procedures, stadards ad workig arragemets; the sufficiecy of resources; the adequacy of risk assessmets ad cotrol systems; ad competecy issues. It recommeded that the Trust udertake sigificat actios to maage risk of recurrece. actios take: 1 The supplier of the defibrillator delivered traiig coverig topics such as cotrols ad visuals, maual operatio ad safety otices ad maiteace. The Trust the assiged a fully traied ad competet device expert to each Assistat Divisioal Officer zoe. Area Traiig Officers were also traied. 2 The Trust provided traiig leads to facilitate istructio for all staff i accordace with the formal programme ad support to the experts to esure that the traiig was completed. The Director of Operatios tasked each Assistat Divisioal Officer with esurig compliace. 3 The Trust itroduced a formal process for idividual members of staff to raise competecy issues ad idetify traiig eeds. outcome of actios take: Competet staff ow use the defibrillator which meas the device is used correctly ad safely. The Trust expects that this will lead to improved patiet outcomes. Learig from the icidet has bee shared with other ambulace trusts via a atioal forum ad to date over 30 staff have used the procedure to access additioal traiig, iformatio, istructio regardig medical devices. A full evaluatio of the system is due to take place ext year. Situatio Lack of robust multi-discipliary traiig ad developmet i the maagemet of obstetric emergecies ad the iterpretatio of cardiotocographs. how it was idetified The gaps were highlighted through the Trust system of formal review ad root cause aalysis for serious patiet safety icidets. The recommedatios from the Cofidetial Equiries ito Materal Deaths ad Stillbirths ad Deaths i Ifacy (4th ad 7th aual reports) drew attetio to the eed for robust forward plaig. Additioally the guidace ad requiremets from the Cliical Negligece Scheme for Trusts iformed the Trust. actio I partership with medical staff ad midwives, the Trust developed a robust twelve moth traiig pla. All staff were iformed of the pla ad this eabled traiig places to be booked i advace to esure operatioal areas were ot depleted of essetial staff. All iformatio is recorded oto the traiig database, which eables maagers to flag up whe staff are due traiig updates. outcome: Traiig ad developmet skills for dealig with obstetric emergecies ad iterpretatio of cardiotocographs is ow part of the culture of the Trust. This is reflected i the Trust achievig Cliical Negligece Scheme for Trusts Materity Stadard Level 3 i Jauary Staff also feel that there is greater cohesio i workig relatios withi the multi-discipliary team. The Trust will be auditig the traiig to determie the impact it has had o practice withi the materity uit. problem: Numerous ligature poits o acute wards resultig i a high risk of patiets attemptig to hag themselves. how it was idetified: A serious patiet safety icidet occurred ad NHS Estates issued a directive shortly afterwards. actio take: Ligature poits steerig group set up which developed a actio pla ad secured aual capital fudig to progress work o reducig the umber of ligature poits i the wards. outcome of actios take: Aalysis of icidets reported shows that there are few occasios whe i-patiets have bee able to use a ligature poit. Whe they have tried to harm themselves, the safety solutios plaed by the steerig group have worked, resultig o ijury or mior ijury to the patiet. A SAfER PLACE for PATIENTS: LEARNING TO IMPROvE PATIENT SAfETY 45

52 part three Case Example 7 Isle of Wight Healthcare NHS Trust Situatio: Research shows that people diagosed with borderlie persoality disorder take up a uduly high percetage of resources, ofte because they drop out ad re-egage or stay with treatmet services for years. High rates of self-harm ad suicidal behaviour ca result i frequet ambulace call-outs ad attedaces at accidet ad emergecy ad admissios to medical ad acute psychiatric services. The Isle of Wight Healthcare NHS Trust oticed a icreasig tred i the umber of their service users diagosed with borderlie persoality disorder. The majority of patiets remaied o the islad with support from commuity ad i-patiet services, as placemets i specialist uits o the mailad were expesive, difficult to secure ad required the patiet to leave behid his or her social etwork. However, staff felt local services were ot ecessarily well equipped to help this cliet group. Actio: I order to address cliical ad fiacial cocers the Trust explored optios for a specialist persoality disorder service. Prelimiary research shows that treatmet combiig cogitive ad behavioural strategies with validatio ad acceptace strategies to ehace cliets commitmet to therapy, icrease adaptive copig ad reduce self-harm ad suicidal behaviours is effective. The Trust therefore developed the Dialectical Behaviour Therapy service. It used staff from existig social work, metal health ad occupatioal therapy services. Therapists atteded a commitmet day to build motivatio ad they ad their maagers siged up to makig time available for traiig as well as deliverig the service. The Trust iitially ivested i traiig for te therapists. Each therapist works part-time o weekly idividual ad group sessios for betwee oe ad three cliets for a year ad is available to be cotacted o the telephoe. Eightee moths after the project bega a audit methodology to quatify the outcomes of the Dialectical Behaviour Therapy was developed. Outcome: Maagers prioritised achievemets for the service as: reduced i-patiet bed use, reductios i suicide ad self-harm ad positive effects o the traied therapists colleagues. The therapists added improved metal health ad quality of life for cliets. I-patiet bed use ad accidet ad emergecy attedace: Psychiatric i-patiet bed use decreased by more tha half, attedace at accidet ad emergecy by 26 per cet ad the use of the Medical Assessmet Uit beds by 94 per cet. (see table below) Icidets of self-harm ad suicidal behaviour: Cliets diary cards showed a decrease i reported self-harm (a full sample was ot available). The modified Self-Harm Ivetory scores revealed a similar tred, but oe cliet who dropped out of the therapy did commit suicide a year later. Other professioals workig with this cliet group also reported decreased icidets of self-harm ad suicidal behaviour. Views o the impact of the service: Colleagues were geerally positive about the programme ad reported that the therapists were sharig useful skills. All cliets agreed that the service was useful ad the majority felt that the Dialectical Behaviour Therapy had helped them to chage egative thought patters or hadle relatioships better. However, they were cocered that there were gaps betwee treatmet sessios ad these eeded to cover weekeds. Improvemets i metal health ad quality of life: Results of psychometric assessmet ad patiet surveys showed some reductios i cliical symptoms, such as depressio, axiety ad depedet persoality features. However, there was a icrease o the hostility ad borderlie persoality sub-scales. Accidet ad Emergecy Medical Beds Psychiatric Beds Total Average cost per patiet Year before Dialectical 3, , , ,113 20,722 Behaviour Therapy Year after Dialectical 2, , , ,635 8,760 Behaviour Therapy Savigs , , ,478 NOTES 1 does ot iclude ambulace call-outs 2 based o te cliets who received the full therapy package ad four service users who participated i the skills group 3 based o bed days ad does ot iclude treatmets or commuity resources eeded by cliets 4 savigs must be off-set agaist the iitial cost of 20,000 ad 30,000 i the secod year. The Trust estimate that o-goig costs will be 10,000 per year for traiig Source: Natioal Audit Office 46 A Safer Place for Patiets: Learig to improve patiet safety

53 part three 3.12 Although researchers have quatified the frequecy of medical errors ad patiet safety icidets, particularly i the Uited States of America, there has bee little work o idetifyig ad evaluatig solutios ad eve less o cost-effectiveess 25. The estimates of the costs of patiet safety icidets icluded i A orgaisatio with a memory 1 aloe suggest that most itervetios ad solutios would have a positive cost-beefit ratio. However few trusts have used a busiess case model to argue for ivestmet i prevetio. Whilst the Natioal Patiet Safety Agecy plas to develop template busiess cases to accompay solutios, by April 2005 oly oe, o ifusio pumps, was available to trusts. Trusts do lear from complaits but more use could be made of this source of iformatio 3.13 We foud 91 per cet of trusts had take steps to iform patiets about how they might raise their cocers about safety, though 20 trusts did so oly if the patiet had already experieced a patiet safety icidet. All trusts had at least oe route through which patiets could raise issues, with four trusts operatig a o-lie reportig system for them Formal patiet complaits ca also be a importat way of esurig that poor or usatisfactory outcomes of care are recogised ad improvemets made ad they ca also be the way that adverse evets are first idetified. Betwee 2001 ad 2004, the Commissio for Health Improvemet s cliical goverace reviews 9 idetified that may barriers existed to patiets makig complaits, ad that it was rare to fid formal systems that esured that complaits would be reviewed, acted upo ad the lessos dissemiated across the orgaisatio From July 2004 resposibility for dealig with complaits that could ot be resolved satisfactorily at the local level passed to the Healthcare Commissio. Sice this resposibility for secod stage complaits was trasferred the umbers made have icreased sigificatly (expected aroud 3,000 per aum, but early 7,000 requests to review complaits have bee received i the first te moths to May 2005). As a result the Healthcare Commissio has focused o hadlig the complaits ad has ot had the time or resources to promulgate wider lessos. The Healthcare Commissio is expected to aalyse ad idetify commo issues ad early fidigs idicate 26 : 60 per cet of referrals i a moth are from the acute sector, with aroud four per cet about metal health services ad oe per cet about ambulace trusts; ad complaits are maily about: poor commuicatio with patiets ad relatives, poor cliical practice, usatisfactory patiet experiece, poor staff attitude ad poor complaits hadlig Sixty-eight per cet of trusts reported that they had ivolved patiets i idetifyig priorities ad 58 per cet i developig solutios through patiet forums, represetatio o trust boards ad via complaits ad claims. This was i cotrast to the YouGov poll 13 where just 30 per cet of seior maagers reported that patiets were actively ivolved i activities to improve patiet safety. Ad i our survey of patiets, six per cet said they were cosulted about how the safety icidet should be preveted from happeig to someoe else ad ie per cet were told what the hospital was goig to do to prevet a similar icidet A third of trusts stated their Patiet Advice ad Liaiso Service was the most effective way patiets could raise their cocers about patiet safety issues, while a quarter felt that complait forms were most effective. I the trusts we visited the Patiet Advice ad Liaiso Service had facilitated ope commuicatio about cocers betwee patiets ad staff ad i may cases preveted these issues from escalatig ito a formal complait or a patiet safety icidet (Case example 8). I most cases the Patiet Advice ad Liaiso Service maager made a report to the committee resposible for patiet safety which was followed by a review by the trust board. Cliical audit is still uder utilised as a learig tool 3.18 Cliical audit is a importat compoet of cliical goverace which helps to idetify deviatios from stadard care practices, icludig cliical icidets, ad has may opportuities for learig. The Commissio for Health Improvemet cocluded i 2004 that NHS trusts were begiig to establish cliical audit strategies based o the Natioal Istitute of Cliical Excellece guidace ad Natioal Service Frameworks. I additio, there were positive treds i the uderstadig ad developmet of cliical audit i some trusts but multi-discipliary approaches to audit were rare ad there was limited dissemiatio of learig 9. A Safer Place for Patiets: Learig to improve patiet safety 47

54 part three Case Example 8 Norfolk ad Waveey Metal Health Partership NHS Trust Situatio: The Savig Lives: Our Healthier Natio target has bee to reduce the suicide rate by at least oe fifth by 2010 ad i 2002 the Trust prioritised the reductio of suicide risks. I developig a actio pla, the Trust wated to icorporate the views of the relatives of patiets who had take their ow lives regardig the potetial risks withi the Trust s policies ad procedures. The Trust orgaised meetigs for relatives ad two represetatives from the Trust to talk through some of the issues surroudig the risks for service users. A group of relatives were the supported to make recommedatios to the Trust aimed at reducig suicide risks. Actio: Durig the two meetigs, the relatives proposed recommedatios ivolvig: patiets access to belts ad shoelaces; availability of iformatio for relatives/carers; traiig of uqualified staff; a amed cotact for the relatives if a patiet dies; ad a sigle poit of etry to each ward. These recommedatios were put to the Trust Board, which agreed with them i priciple but also stressed that the privacy ad digity of patiets should be cosidered at all times. Outcome: All these poits were actioed. The Trust revised its cliical stadards o Additioal Observatio of Patiets at Risk, icludig the eed for the documetatio of the ratioale for the removal/ or ot of potetial risks of self-harm ad ivolvig the patiet ad carer/relative i the decisios for the care pla. Guidace was issued to staff about ivolvig relatives i risk assessmets. The Commuicatios of Cliical Risk policy was agreed which details whe the Trust may be obliged to breach cofidetiality. Uregistered staff ow have traiig regardig physical health moitorig, i additio to the same madatory traiig i basic life support as registered staff. The Trust ow icludes a amed cotact i its icidet file if a patiet dies. All acute i-patiet wards were re-desiged to esure oly oe poit of etry ad exit ad the urses statios were moved ext to the etrace for better observatio. The Trust have also recetly itroduced a swipe card system for staff ad patiets i oe area. This system is plaed for the remaiig adult acute i-patiet wards. The Trust has see a reductio i the umber of i-patiet deaths as a result of suicide. Source: Natioal Audit Office 3.19 A umber of the Royal Colleges have worked with specialties, such as cardiothoracic surgery ad itesive care, to implemet stadardised cliical audits i all relevat trusts. These provide a evidece base for evaluatig cliical care ad i the last two years the Royal Colleges have published the outcome for idividual trusts; highlightig lessos ad raisig performace. From April 2004, the Healthcare Commissio assumed resposibility for developig a atioal programme of cliical audit ad for evaluatig compliace. Case example 9, illustrates the approach of oe ambulace trust i usig cliical audit to improve outcomes for its patiets. Trust-wide applicatio of lessos ad embeddig of learig is patchy 3.20 To esure effective orgaisatioal learig followig patiet safety icidets it is essetial to cascade lessos leart to the relevat staff groups ad moitor their compliace with this ew iformatio. Trusts shared the examples of lessos leart through cliical goverace reports, iteral risk maagemet reports ad trust wide ad departmetal ewsletters, but most used a combiatio of methods to dissemiate learig, icreasig the chace that the message gets through (Figure 17 overleaf) The Natioal NHS Staff Survey showed that oly 29 per cet of respodets felt that the differet parts of their trust commuicated effectively with oe aother. We foud there were other barriers to implemetig lessos leart, though may trusts had take actio to overcome these (Figure 18 overleaf). There were also wide variatios i the systems for embeddig orgaisatioal learig. Where moitorig of lessos idetified a lack of implemetatio, may trusts placed the issue o the risk register, facilitated discussio of the issues betwee the maagemet ad staff, or gave resposibility for close moitorig to a specific committee or group The Natioal NHS Staff Survey 6 also foud that oly 43 per cet of staff felt that their trust built strog co operative liks with other orgaisatios. Our results also showed that sharig of best practice with exteral orgaisatios was very patchy, with 63 per cet of trusts surveyed sharig learig with other local trusts, ofte through orgaised etworks or the Ambulace Service Associatio. 48 A Safer Place for Patiets: Learig to improve patiet safety

55 part three Case Example 9 Staffordshire Ambulace Service NHS Trust Situatio: Coroary Heart Disease is the sigle most commo cause of premature death i the Uited Kigdom ad ambulace services deal with a sigificat umber of patiets with this disease. Durig cardiac arrest a lack of oxyge causes brai ijury withi four miutes ad death will occur withi twelve if o therapy is give. Therefore optimal survival depeds primarily o early access to emergecy medical services, early cardiopulmoary resuscitatio, early defibrillatio ad early advaced life support. I Staffordshire approximately 3,000 people die prematurely each year as a result of cardiac arrest ad Staffordshire Ambulace Service NHS Trust has adopted a umber of procedures to improve its performace i treatig these patiets. There is clear evidece that appropriate itervetio leads to icreased chaces of survival ad the Trust uses the Advaced Medical Priority Dispatch System, which has a high sesitivity for idetifyig cardiac arrest cases ad allows the call-taker to give pre-arrival istructios, to maximise the assistace offered to the patiet before paramedics atted the scee. Although the Departmet s miimum respose time is eight miutes the Trust expects the first paramedic to arrive o the scee withi 4 miutes ad 59 secods. The Trust has also purchased 12 lead Electrocardiograms to allow pre-hospital thrombolysis to be admiistered ad Zoll defibrillators which store cliical performace data. Actio: The Cliical Audit Departmet measure ad audit each idividual case of cardiac arrest ad acute myocardial ifarctio atteded by the Trust, usig paper ad electroic patiet report forms. It matches the dispatch system records with the electrocardiogram ad defibrillator data, such as cardiac waveforms, blood pressures, pulse oxyimetry ad a audio recordig of the evet. Outcome: Ambulace crews reached 50 per cet of calls withi 4 miutes ad 59 secods. Retur of spotaeous circulatio has icreased from per cet i to per cet i The results of the audit ad aoymous reportig of cocers about poor executio of chest compressios led to the Trust purchasig equipmet to provide mechaical chest compressio/heart massage for commuity paramedics to use durig cardiopulmoary resuscitatio. The Trust is ow itroducig these devices ito the ambulace fleet. To esure that patiets receive the most effective treatmets the Trust hopes to collaborate with acute trusts to facilitate the audit of the complete care pathway. The umber of patiets receivig pre-hospital thrombolysis i Staffordshire has icreased from 137 i to 288 i Cumulative umber of patiets thrombolysed March 2003 May 2003 July 2003 Sept 2003 Nov 2003 Ja 2004 March 2004 May 2004 July 2004 Sept 2004 Nov 2004 Dec 2004 Ja 2005 Feb 2005 Source: Natioal Audit Office A Safer Place for Patiets: Learig to improve patiet safety 49

56 part three 17 How trusts dissemiate lessos leart All trusts use at least oe method to dissemiate lessos leart. Method of dissemiatio discussio at relevat hospital-wide meetig groups discussio by local meetig groups resposible for patiet safety by mail/ to local maagers, e.g. ward sisters, who cascade it to other staff trust s itraet ewsletters 3.23 Niety-oe per cet of trusts stated that they shared lessos with their strategic health authorities, but the trusts we visited felt that they were ot receivig sufficiet feedback. I cotrast, although half of strategic health authorities used cliical goverace etworks as a opportuity to dissemiate learig ad good practice, they reported that trusts were ofte reluctat to share their lessos. NHS orgaisatios were cocered that as foudatio trusts are ot required to report to strategic health authorities that they could miss out o iformatio Sice summer 2004, the Natioal Patiet Safety Agecy s 28 Patiet Safety Maagers have bee workig with most trusts to help share good practice ad develop local solutios. Patiet Safety Maagers are well placed to improve the liks betwee trusts ad their strategic health authority ad to share learig locally (Case example 10). However, just 19 per cet of trusts had shared lessos with the Natioal Patiet Safety Agecy ad there was a perceptio that it was ot iterested i dissemiatig learig from idividual trusts atioally. Three-quarters of trusts did say that they were plaig to icrease the extet to which they shared lessos leart with other orgaisatios Source: Natioal Audit Office survey of NHS acute, ambulace ad metal health trusts Barriers other Barriers to lessos leart Difficulty i commuicatio Fiace ad resources Cultural difficulties percetage of trusts usig particular method Actios to address barriers Improvemet of distributio ad commuicatio system Itroductio of ewsletters Itraet Prioritisig actios Risk assessmets ad risk registers Educatio ad traiig to icrease awareess Natioally the focus has bee o processes ad systems rather tha orgaisatioal learig Safety alerts ca be a effective way of esurig solutios are implemeted, but compliace must be audited 3.25 A umber of NHS orgaisatios used safety alerts as a key tool for sharig lessos leart but there was little moitorig or iformatio as to whether trusts were actig o them. I 2003, the Departmet piloted a system to follow-up o these alerts. After a successful six moth pilot, the Departmet itroduced a electroic system (Safety Alert Broadcast System) i which a omiated resposible perso from each trust (geerally the Medical Device Liaiso Officer) was required to ackowledge the receipt of the alert ad record the actios the trust had take, i relatio to the deadlie for completig actio o the alert. Strategic health authorities are resposible for moitorig the resposes. Fair-blame culture Source: Natioal Audit Office survey of NHS acute, ambulace ad metal health trusts A Safer Place for Patiets: Learig to improve patiet safety

57 part three Case Example 10 Northumberlad ad Tye ad Wear Strategic Health Authority Situatio: The Strategic Health Authority idetified patiet safety ad cliical goverace as key priorities ad that more work eeded to be doe to esure trusts across the patch leared from each other to improve their service. Actio: It udertook a three moth programme of iformal visits to each NHS orgaisatio to gai a uderstadig of the various approaches to cliical goverace ad subsequetly established a Cliical Goverace Forum i November This icluded all acute, ambulace, metal health ad primary care trusts ad has recetly bee exteded to iclude represetatives from the Idepedet Sector. NHS Direct ad the Natioal Patiet Safety Agecy s Patiet Safety Maager were also active participats. All stakeholders, cotributed to the terms of referece. The Forum meets quarterly ad focuses o: orgaisatioal culture ad structure i relatio to cliical goverace; specific cliical goverace topics ad priorities o the trust-led ageda; the sharig of good practice; ad etworkig betwee colleagues across orgaisatioal boudaries. A cliical goverace etwork, structured aroud the Cliical Goverace Forum, has evolved based upo streams of work coverig all cliical goverace areas ad icorporatig relevat issues raised by other etworks (for example the seior urse group). Uderpiig this etwork is the theme that cliical goverace is everybody s busiess ad it operates with the Cliical Goverace Forum at its hub. It ecourages active stakeholder participatio ad a series of targeted educatioal evets supports its developmet. The aual Cliical Goverace Coferece is cetral ad it egages up to 300 health professioals, support staff, cliical goverace leads, delegates from staff orgaisatios ad patiet represetatives, through a high quality programme delivered by atioal speakers. The etwork also provides a framework through which the Natioal Patiet Safety Agecy ca egage i the local cliical goverace ageda, meetig the eeds of the local health ecoomy ad atioal programme priorities. This covergece of agedas betwee the Strategic Health Authority ad Natioal Patiet Safety Agecy allows closer workig o cliical goverace issues ad helps maximise the potetial for the spreadig of good practice ad the dissemiatio of lessos leared from serious utoward icidets. Oe such example of this syergy was the Mid the Gap regioal workshop held o 12 July 2004 i which the strategic health authorities ad trusts i the orth of Eglad met to clarify the roles ad resposibilities of orgaisatios i the sharig of learig ad good practice. The Natioal Patiet Safety Agecy s Patiet Safety Maager has also participated i the review of the Strategic Health Authority serious utoward icidet policy ad maitais a regular office presece as a importat stakeholder i the output of the cliical goverace team. I additio, the Natioal Patiet Safety Agecy has delivered Root Cause Aalysis traiig across all trusts withi the Strategic Health Authority, drive the cleayourhads campaig aimed at prevetig the spread of ifectio, ad has bee workig to develop trust readiess for Cliical Negligece Scheme for Trusts assessmet. The Strategic Health Authority has worked with local trusts to iclude local priorities ito the framework of cliical goverace plas, for istace hospital acquired ifectios ad suicide ad child protectio, ad broadeed its egagemet o cliical goverace issues through the secodmet of a risk maager from a local acute trust for oe day a week over a period of 18 moths. The secodee has developed local learig lessos bulletis, each based aroud a particular theme, with iput from the Natioal Patiet Safety Agecy s Patiet Safety Maager. The Strategic Health Authority is buildig o it to produce techical bulletis ad a ewsletter icorporatig a regular feature from the Natioal Patiet Safety Agecy. Outcome: Trusts are very positive about the efforts made by the Strategic Health Authority to share learig ad the ivolvemet of the Patiet Safety Maager. The aual Cliical Goverace Coferece is highly rated. The Patiet Safety Maager is actively idetifyig lessos leart locally ad askig for more iformatio about these issues. The Strategic Health Authority has promoted a proactive safety culture emphasisig that risk maagemet should be a itegral part of all trusts operatios through its etwork ad bulletis. Source: Natioal Audit Office A Safer Place for Patiets: Learig to improve patiet safety 51

58 part three 3.26 Betwee April 2004 ad April 2005, trusts received 93 alerts ad ackowledged them i 99.7 per cet of cases. The alert issuig orgaisatios do ot have the remit or fuds to ivestigate how the advice was used ad durig our visits we foud examples where trusts had siged up to udertake specific actios but whe resources were ot forthcomig, a similar icidet occurred. The Chief Medical Officer, i his aual report for , highlighted the fact that some self-reports of compliace with the removal of o-collapsible rails i metal health services proved ureliable, ad oly 54 per cet of orgaisatios had fully completed the actios required to reduce harm from oral methotrexate 50 days beyod the deadlie. Although he questioed whether some deadlies were realistic, the Chief Medical Officer suggested that the geeral problem with implemetig alerts is at least partly due to the curret safety culture i the NHS, rather tha the method of dissemiatio of iformatio about risks to patiets ad how to reduce those risks. For the year the Healthcare Commissio, i assessig trust performace agaist the Stadards for Better Health, will be checkig o trusts self-assessmets assertig that they have implemeted all relevat alerts at a sample of trusts Not all atioal orgaisatios that issue healthcare alerts curretly participate i the Safety Alert Broadcast System. The most otable omissio is the drug alerts from the Medicies ad Healthcare products Regulatory Agecy (it issues these by a alterative system that operates all hours). Durig , the Medicies ad Healthcare products Regulatory Agecy issued 63 medical device safety alerts which required actio from trusts ad some also provided advice o evirometal ad usage factors. The trusts we visited told us that the medical device safety alerts they received were very useful to maitai patiet safety I total the Natioal Patiet Safety Agecy has issued six patiet safety alerts ad six other otices sice it was established (Appedix 6). Although the Natioal Patiet Safety Agecy alerts helped raised the profile of the particular issue cocered, trusts told us that they rarely provided ay ew iformatio. There was also a perceptio that the alerts were too acute-trust focused, cotradicted other guidace, ad did ot apply across trusts ad that the Natioal Patiet Safety Agecy had ot cosidered the cost implicatios for implemetig them. For example, to comply with a alert advisig acute trusts to use alcohol gel trusts were required to idetify sigificat resources out of their existig budget. Trusts told us that they wated the Natioal Patiet Safety Agecy to develop more iovative lessos ad real solutios to o-goig patiet safety issues rather tha issue safety alerts o subjects of which they were already aware. There are opportuities to improve learig at regioal ad atioal level 3.29 The preset system for aalysig ad dissemiatig lessos leart is depedet upo trusts reportig a patiet safety icidet. If trusts devise ad implemet strategies to desig out risks before a icidet occurs the this learig remais at the local level. I additio, improvemets after patiet safety icidets are depedet upo trusts carryig out their plaed actios ad embeddig the learig i their ow practice At a regioal level, strategic health authorities are well placed to facilitate learig but we foud that geerally learig came from trusts ow experieces. Followig the report of a serious utoward icidet, trusts are required to record the actios take ad lessos leart. May strategic health authorities told us that at preset they lack the resources to fully moitor all these reports or dissemiate the learig from them. At best they reviewed the ivestigatio reports ad resultat actio plas ad ra tred aalysis o utoward icidets to idetify high risk areas (Illustrative examples 6) Oly eight strategic health authorities gave examples of itervetios followig a serious utoward icidet, usually where the competece of a health professioal was i questio. We foud that strategic health authorities did ot have itegrated systems to lear from serious utoward icidets, complaits ad litigatio cases, maily because differet parts of the orgaisatio dealt with complaits ad litigatio. There was also o evidece of moitorig of these latter areas for learig poits. Although most strategic health authorities provided feedback to trusts followig their moitorig of cliical goverace developmet plas, they did ot moitor trusts implemetatio of recogised good practice ad the lessos leart Trusts we visited told us that they had set icidet reports to the Natioal Patiet Safety Agecy via the Natioal Reportig ad Learig System but had received othig back. Our survey showed trusts wated the Natioal Patiet Safety Agecy to provide feedback o treds i icidet reportig so that they could assess their positio ad track their improvemets relative to similar orgaisatios. I July 2005, the first report 5 of the Patiet Safety Observatory was published. Whilst this maily 52 A Safer Place for Patiets: Learig to improve patiet safety

59 part three Illustrative examples 6 Map to show actio take i strategic health authorities to improve patiet safety Cumbria ad Lacashire The cliical goverace team iform all executive directors, commuicatio ad goverace leads regardig all serious utoward icidet reports to esure the executive directors are briefed if they are o call, the appropriate cross office liks are made ad SHA actio co-ordiated. Dorset ad Somerset After the Willis review agaist the Risk Poolig Scheme for Trusts ad the Cliical Negligece Scheme for Trusts i , the Strategic Health Authority orgaised a semiar for local trusts. This was a opportuity to lear from the expertise of the Willis team, to de-mystify the trusts perceptios of reportig requiremets for both schemes ad to obtai aswers to queries, facilitatig the sharig of good practice. Breakout sessios were orgaised as part of the evet which eabled trusts to work together o how to preset themselves i assessmet. All trusts ow have bee assessed as meetig Level 1 or above. Thames Valley I November 2004 the Cliical Goverace Maager orgaised a Thames Valley Safety Evet which was a oe day free workshop orgaised i partership with the Natioal Patiet Safety Agecy for all staff with resposibility for risk maagemet, health ad safety or ay other member of staff i a appropriate role. This was a opportuity to raise awareess of safety issues for both staff ad patiets ad to share learig from specific icidets. It icluded a update o likig to the Natioal Reportig ad Learig System ad a presetatio o the Natioal Patiet Safety Agecy s Seve steps guidace to support implemetatio across Thames Valley. North East Lodo The Strategic Health Authority dissemiated learig ad good practice through presetatios at sector specific groups, Cliical Goverace etworks ad a quarterly ewsletter that icludes a icidet summary ad a outlie of actios. North ad East Yorkshire ad North Licolshire The lead o Patiet Safety has met with the local Patiet Safety Maager ad oe of the joit Chief Executives of the Natioal Patiet Safety Agecy to review joit workig arragemets. This icluded a detailed update of where all 17 trusts withi the Strategic Health Authority are i relatio to the Natioal Patiet Safety Agecy iitiatives o potassium chloride, stadard crash calls, methotrexate, ear patiet alcohol gel ad ifusio devices. Essex At the bi-mothly Cliical Goverace ad Risk Maagemet members exchage icidets are discussed ad good practice or areas for improvemet are idetified. Miutes are circulated to all trusts to facilitate further learig. The local Natioal Patiet Safety Agecy s Patiet Safety Maager sits o all the committees ad feeds i the atioal perspective. I additio, the Risk Maagemet Committee of the Strategic Health Authority (SHA) receives iformatio ad itelligece from the Patiet Safety Maager ad from other sources from which it distils learig ad good practice. Source: Natioal Audit Office survey of strategic health authorities 2004 A Safer Place for Patiets: Learig to improve patiet safety 53

60 part three focused o a aalysis of the icidets reported to the Natioal Reportig ad Learig System, it also provided illustrative examples of how these reports were beig used: the Natioal Reportig ad Learig System received reports of 311 icidets liked to aticoagulat medicie, icludig two deaths. The Natioal Patiet Safety Agecy obtaied iformatio from medical defece ad egligece bodies, where i 600 cases betwee 1990 ad 2002, oe i five (120) reports were of the death of a patiet, ad solutios are ow beig developed i collaboratio with the British Society for Haematology; 493 reports from 45 trusts with problems with patiet idetificatio, icludig oe i eight icidets ivolvig wristbads. Aalysis showed a lack of systematic ad stadardised processes to support idetificatio ad the Natioal Patiet Safety Agecy expects to promulgate advice i the autum of 2005; ad a review of reported deaths revealed some cardiac arrest icidets were the result of equipmet problems o the crash call trolley. The Natioal Patiet Safety Agecy is collaboratig with the Hele Hamly Trust to fud the desig of a crash call trolley that elimiates risks aroud missig equipmet. There is scope to improve evaluatio ad dissemiatio of learig by other NHS orgaisatios 3.33 I 2001, the Departmet proposed 3 that there should be a sigle system to share lessos o patiet safety that would draw o iformatio, research ad aalysis from a variety of sources. However, we foud that a umber of orgaisatios have cotiued to share lessos through their ow systems (Illustrative examples 7). These lessos were ofte idetified from the orgaisatio s ow data sources so there is the potetial for duplicatio ad cotradictory advice The Healthcare Commissio has archived the evidece base collected durig the Commissio for Health Improvemet s cliical goverace reviews at idividual trusts. Whilst three atioal reports 9 were published, coverig a wide umber of issues, the Healthcare Commissio have ot iterrogated the remaiig body of evidece to promulgate learig about patiet safety ad related issues. Illustrative examples 7 The work of the NHS Litigatio Authority I the last two years, the NHS Litigatio Authority has begu to establish itself as more of a learig orgaisatio. It has built o its established etwork of cotacts i trusts to publicise high-risk areas ad provide risk educatio activities for cliicias. It has produced a variety of risk maagemet publicatios, icludig the log established NHSLA Review, ad held two cofereces ad other traiig evets. Sice October 2003, trusts ad researchers have bee able to request aalyses of claims data from the Cliical Negligece Scheme for Trusts ad the Risk Poolig Schemes for Trusts to assist i risk maagemet. I 2004 the NHS Litigatio Authority formalised a system for the sharig of otable practice idetified durig its risk maagemet assessmets uder which trusts ca request assistace o a particular issue ad be put i touch with other trusts that have devised practical solutios. A study 27 of NHS Litigatio Authority data idetified those procedures ad specialties at most risk of litigatio. This iformatio could help trusts i developig their risk registers. The work of the Medicies ad Healthcare products Regulatory Agecy The Medicies ad Healthcare products Regulatory Agecy draws o iformatio obtaied through logstadig atioal reportig systems ad other data sources, such as the GP Research Database, to miimise the risks from the maufacture of medical devices ad medicies to patiets. Oe report is sufficiet to trigger ivestigatio ad if the Medicies ad Healthcare products Regulatory Agecy receives otificatio of serious icidets or early idicatios of problems, it is able to use its resources to idetify corrective actio. For example every medical device icidet reported through its Adverse Icidet Reportig System is risk assessed to idetify areas that require ivestigatio. I over 50 per cet of cases ivestigators foud the icidet was due to a problem with the use of the device i the hospital, primarily aroud poor traiig, learig ad maagemet issues. The Medical Device Liaiso Officer i each trust ca access dedicated pages o the Medicies ad Healthcare products Regulatory Agecy s website ad they ad other staff such as the Pharmacy Leads atted study days ad cofereces o importat safety issues. The Medicies ad Healthcare products Regulatory Agecy also dissemiates learig through publicatios such as Curret Problems i Pharmacovigilace ad Oe liers ad has bee workig with other NHS bodies, such as the Natioal Patiet Safety Agecy, to develop traiig programmes to assist i chagig healthcare professioals practices. Source: Natioal Audit Office 54 A Safer Place for Patiets: Learig to improve patiet safety

61 part three The strategy for the Patiet Safety Research Programme has yet to have a impact o frotlie healthcare delivery 3.35 Buildig a safer NHS for patiets 3 idetified the key role that research ca play i uderstadig the huma factors that cause uiteded harm ad i developig patiet-focused solutios to embed i practice across the NHS. Compared to other idustries, research o learig from errors i healthcare was relatively uder-developed. I 2001, the Departmet proposed a programme of research, with specific foci for the work, ad the Programme Director made a commitmet to cocetrate o prescribig errors ad patiet safety durig labour To date the Patiet Safety Research Programme i Eglad ad Wales has published reports from te of the projects it commissioed, at a cost of aroud 400,000, ad there are a further 18 studies i progress (there are 46 projects i the pipelie with a total value of 8.9 millio). The reports have provided a backgroud o reportig systems ad cofirmed the approaches eeded to improve patiet safety. Key fidigs are: reportig systems ad discipliary arragemets eed to be separate ad feedback from ay reportig system is vital to maitai cliicias iterest; the prevailig legal system does ot ecourage health professioals to be ope after a adverse patiet safety icidet ad they eed to be equipped with skills to deal with discussios where errors are disclosed; cliical iexperiece; lack of supervisio ad traiig; heavy workloads ad staff shortages; lack of equipmet ad poor commuicatio are the root causes of errors i materity care; firm cetral directio is eeded if patiet safety systems are to be effectively implemeted; evaluatio of the effectiveess of educatioal itervetios or icetives is eeded; ad egieerig ad psychology could be used together to desig systems which may be more resistat to error whe humas use medical techology. Developmets i iformatio techology should help improve patiet safety 3.37 Prevetig errors by the appropriate use of iformatio techology is well established. The Istitute of Medicie i the Uited States of America advised that movig from a paper to a electroic based patiet record system would be the sigle step that would most improve patiet safety 28. The Natioal Programme for Iformatio Techology i the NHS beig delivered by the Departmet s agecy, NHS Coectig for Health, has begu to roll out its Natioal Care Record system ad expects it to have full fuctioality by Most trusts foresee that this will help them i esurig that patiet records are o loger lost ad there are better cotrols over prescribig (both issues have led to sigificat umbers of patiet safety icidets). Buildig a safer NHS for patiets 3 made a case for research to uderpi how best to utilise experts, lear lessos ad dissemiate them. The programme has yet to deliver o these. A Safer Place for Patiets: Learig to improve patiet safety 55

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