Patient safety: thinking differently

1. Patient safety: thinking differently Exploring the challenges in patient safety improvement from national, local and personal perspectives Frances Healey, RGN, RMN, PhD Head of Patient Safety Insight, NHS England 1 April 2015

3. to save 6000 lives Patient Safety Collaboratives System wide campaign Vulnerable groups Vulnerable points of care Patient Safety ’Fellows’ Tackling key patient safety priorities NHS England’s Integrated Patient Safety Strategy for the NHS Key types of harm A system devoted to continual learning and improvement Enhancing NHS capability and capacity to improve safety NaPSAS Data Transparency Gaining a better understanding of what goes wrong in healthcare SAFE team Retrospective case note review NRLS and reduce harm by 50% www.england.nhs.uk

4. 2014 Around 12,000,000 incidents have been reported. Approximately 4,000 incidents are reported to the NRLS per day Around 94% of incidents cause low or no harm

5. Scale of the problem: reported incidents • Each report an opportunity to learn: 68% no harm & 25% low harm • But each report also represents actual or potential distress or harm to patients and concern from staff NRLS Quarterly Data workbooks April 2012 – March 2013 England data: 1,353,430 incidents in total

6. “But we are interested in future harm, not past harm” • We need to embrace the challenges and opportunities set out by the Health Foundation’s The measurement and monitoring of patient safety • But past harm matters because: • The NHS today is not so very different from the NHS earlier this year; our processes, pressures, patient groups, staff, buildings, equipment, and training will not have radically changed since the period these data are drawn from • Therefore the patterns of human error, and poorly designed systems that fail to prevent harm reaching the patient, are likely to recur until we make improvements

7. Don’t count incident reports, read them….

8. to save 6000 lives Patient Safety Collaboratives System wide campaign Vulnerable groups Vulnerable points of care Patient Safety ’Fellows’ Tackling key patient safety priorities NHS England’s Integrated Patient Safety Strategy for the NHS Key types of harm A system devoted to continual learning and improvement Enhancing NHS capability and capacity to improve safety NaPSAS Data Transparency Gaining a better understanding of what goes wrong in healthcare SAFE team Retrospective case note review NRLS and reduce harm by 50% www.england.nhs.uk

9. National Patient Safety Alerting System (NaPSAS) • A new system launched in January 2014 for alerting the NHS to emerging patient safety risks • Builds on the best elements of the former National Patient Safety Agency (NPSA) system • A three-stage alerting system based on other high risk industries such as aviation www.england.nhs.uk

10. Potential new risks received from: Resolution: Triage: NO ACTION - risk not significant - action already underway - action not feasible NRLS death & severe Coroners Discussion Information gathering Detailed insight from expert groups Decision FOR ACTION BY OTHERS Information handed over NHS staff Professional bodies NaPSAS ALERT Warning Resource Directive Other national organisations FOR OTHER ACTION e.g. social movements, collaboratives, education, etc. Public/patients Clinical audit/mortality

11. Targeted audience ‘Story’ of trigger incident Number and nature of similar errors

12. Works with differing levels of organisational maturity E. Risk management is an integral part of everything that we do D. We are always on the alert for risks that might emerge C. We have systems in place to manage all identified risks B. We do something when we have an incident A. Why waste our time on safety? PATHOLOGICAL REACTIVE BUREAUCRATIC PROACTIVE GENERATIVE The Manchester Patient Safety Assessment Framework

13. to save 6000 lives Patient Safety Collaboratives System wide campaign Vulnerable groups Vulnerable points of care Patient Safety ’Fellows’ Tackling key patient safety priorities NHS England’s Integrated Patient Safety Strategy for the NHS Key types of harm A system devoted to continual learning and improvement Enhancing NHS capability and capacity to improve safety NaPSAS Data Transparency Gaining a better understanding of what goes wrong in healthcare SAFE team Retrospective case note review NRLS and reduce harm by 50% www.england.nhs.uk

14. Scale of the problem: death & severe harm Over 8,000 reported fatal or severe harm incidents each year NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data: 8,018 incidents

15. Scale of the problem: other sources • Around 4,400 people commit suicide each year; 27% are known to mental health services; most are known to GPs • 4,849 deaths related to VTE within 120 days of hospital admission (for reasons other than VTE) each year • 9,500 patients with grade 2/3/4 pressure ulcers on each monthly survey • Around 3,000 hip fractures from falls in hospitals each year identified by the National Hip Fracture database Suicides - England 2002-2012 • The largest areas of harm remain large because they are ‘wicked problems’ which need complex, wide-ranging and sustained improvement efforts: NCISH 2014 report - HSCIC NHS OF Aug 2014 - Safety Thermometer Sept 2014 – NHFD 2014 report

16. 2007 2015 2014 2020

17. to save 6000 lives Patient Safety Collaboratives System wide campaign Vulnerable groups Vulnerable points of care Patient Safety ’Fellows’ Tackling key patient safety priorities NHS England’s Integrated Patient Safety Strategy for the NHS Key types of harm A system devoted to continual learning and improvement Enhancing NHS capability and capacity to improve safety NaPSAS Data Transparency Gaining a better understanding of what goes wrong in healthcare SAFE team Retrospective case note review NRLS and reduce harm by 50% www.england.nhs.uk

18. 5% of deaths potentially avoidable Median age 80 years • Main problem types: • Clinical monitoring (in the broad sense) 31% • Diagnostic error & delay 30% • Fluids and medication 21% • Average 4 problems in healthcare per avoidable death

19. Not classic Swiss cheese “bull’s eye” Patient Safety Incident

20. Cumulative effect of more minor harms“death by a thousand cuts” Patient

21. Problems in healthcare • Female patient in her 80s with a past history of stroke was admitted with a chest infection. An early CT scan showed a dilated oesophagus with food residue. She was kept nil by mouth for 5 days waiting for a swallowing assessment (problem 1/diagnosis and assessment). Fluid balance during that period was poorly charted (problem 2/clinical monitoring) but laboratory tests indicated developing dehydration. No changes in fluid regime were made in response (problem 3/drugs and fluids). On day 5 a trip over the drip stand (problem 4/other) led to a fractured femur. The patient died from post -operative renal failure, to which her poor preoperative state had contributed. Are you confident potentially avoidable deaths discussed in mortality meetings are reported as incidents and known to your Board?

22. to save 6000 lives Patient Safety Collaboratives System wide campaign Vulnerable groups Vulnerable points of care Patient Safety ’Fellows’ Tackling key patient safety priorities NHS England’s Integrated Patient Safety Strategy for the NHS Key types of harm A system devoted to continual learning and improvement Enhancing NHS capability and capacity to improve safety NaPSAS Data Transparency Gaining a better understanding of what goes wrong in healthcare SAFE team Retrospective case note review NRLS and reduce harm by 50% www.england.nhs.uk

23. Acute care settings: patient age within death and severe harm incidents NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data

25. to save 6000 lives Patient Safety Collaboratives System wide campaign Vulnerable groups Vulnerable points of care Patient Safety ’Fellows’ Tackling key patient safety priorities NHS England’s Integrated Patient Safety Strategy for the NHS Key types of harm A system devoted to continual learning and improvement Enhancing NHS capability and capacity to improve safety NaPSAS Data Transparency Gaining a better understanding of what goes wrong in healthcare SAFE team Retrospective case note review NRLS and reduce harm by 50% www.england.nhs.uk

27. Hierarchy of activities not done Recap: types of ward level indicator Therefore measuring a few processes that are easier to measure gives a good indication of what other activities will also have been delivered /not delivered

28. And the response to NHS Choices publication?

29. Are we ready to measure frontline care? 28% No medical role in fall prevention policy “This [MH unit for older people] has no physio input. Balance and strength assessments never get done” 46% Risk scores incompatible with guidelines 70% No access to new walking aids at weekends Royal College of Physicians 2012 Report of the 2011 inpatient falls pilot audit www.rcplondon.ac.uk

30. to save 6000 lives Patient Safety Collaboratives System wide campaign Vulnerable groups Vulnerable points of care Patient Safety ’Fellows’ Tackling key patient safety priorities NHS England’s Integrated Patient Safety Strategy for the NHS Key types of harm A system devoted to continual learning and improvement Enhancing NHS capability and capacity to improve safety NaPSAS Data Transparency Gaining a better understanding of what goes wrong in healthcare SAFE team Retrospective case note review NRLS and reduce harm by 50% www.england.nhs.uk

31. Archie Cochrane http://blogs.bmj.com/bmj/2014/05/09/tara-lamont-on-failing-well-archie-cochranes-legacy/ @TaraJLamont www.england.nhs.uk

32. “The results at that stage showed a slight numerical advantage for those who had been treated at home. It was of course completely insignificant statistically. “I rather wickedly compiled two reports, one reversing the numbers of deaths on the two sides of the trial. As we were going into committee, in the anteroom, I showed some cardiologists the results…….. www.england.nhs.uk

33. “……they were vociferous in their abuse: `Archie’, they said, `we always thought you were unethical. You must stop the trial at once…’ “I let them have their say for some time and then apologised and gave them the true results, challenging them to say, as vehemently, that coronary care units should be stopped immediately. “There was dead silence and I felt rather sick because they were, after all, my medical colleagues.” Professor Archibald Cochrane & Max Blythe One Man's Medicine (1989) p.211

34. “cognitive dissonance” http://britishgeriatricssociety.wordpress.com/2013/05/16/all-down-to-numbers/ “data used for reassurance”

35. HSJ November 2011 (response to first SHMI publication) Dr X, Medical Director at Trust A blamed his organisation's rating on the inclusion of data from a hospice which is not run by the Trust. Trust B said that the new indicator does not take into account levels of deprivation which has put it at a disadvantage. However Trust C said it was taking the rating "extremely seriously" and has commissioned an external review.

36. “There is no such thing as patient safety culture”

37. The NPSA Incident Decision Tree Based on James Reason’s culpability model Were the adverse consequences intended? Is there evidence of physical or mental ill-health? YES Guidance on appropriate management action, centred on criminal sanctions Guidance on appropriate management action, centred on support to become fit to work safely again Guidance on appropriate management action, may be training/insight/supervision needs Guidance on appropriate management action, centred on disciplinary sanctions No management action to be directed at staff involved- systems failure

38. to save 6000 lives Patient Safety Collaboratives System wide campaign Vulnerable groups Vulnerable points of care Patient Safety ’Fellows’ Tackling key patient safety priorities NHS England’s Integrated Patient Safety Strategy for the NHS Key types of harm A system devoted to continual learning and improvement Enhancing NHS capability and capacity to improve safety NaPSAS Data Transparency Gaining a better understanding of what goes wrong in healthcare SAFE team Retrospective case note review NRLS and reduce harm by 50% www.england.nhs.uk

40. "The consistent delivery of well-executed safe care under typically difficult circumstances tends to go unrecognised" http://m.qualitysafety.bmj.com/content/23/11/880.full

41. Thank you! frances.healey@nhs.net @FrancesHealey