1. Supporting Trusts to Use a Broader Range of Data Sources for Monitoring Patient Safety A toolkit for Patient Safety Managers Produced by Dr Helen Hogan, Specialist Registrar London School of Hygiene and Tropical Medicine

2. Learning about the scale and nature of key risk areas: two approaches In depth analysis of individual PSIs Epidemiological approach focusing on analysis of groups of PSIs Good for identifying underlying process and system failures Good for identifying the scale of the problem, trends, clusters and risk factors

3. Root cause analysis (RCA) of individual PSI Local Risk Management Systems Patient Administration System National Confidential Enquiries IndividualPopulation Aggregated RCAs Sources of Information on PSIs

4. Disadvantages of relying on single source Local Risk Management Systems Under reporting at both ends (no harm and serious) More likely to receive reports from particular healthcare worker groups e.g. nurses More likely to receive reports of certain types of injury e.g. falls Relying on this source alone does not give the whole picture

5. The broader approach to surveillance and monitoring Bringing together information from a range of sources provides a better picture of the scope and scale of key patient safety risks Different sources identify different types of incidents causing differing levels of harm International experience supports this approach- recent study by the AHRQ in the USA highlighted the need to triangulate findings from LRMS with other data sources to identify appropriate interventions 1

6. Which information sources might hold useful patient safety information? Incident Reporting Systems Surveillance Systems AuditOther Sources  Clinical Incidents  Health and Safety Incidents  Complaints  Claims  Inquests  Medical and Healthcare Products Regulatory Agency Reporting System  EBME local incident reporting system  Pathology local incident reporting system  Infection Control Team incident reporting system  Radiology reporting system  Endoscopy incident reporting system  Mandatory MRSA bacteraemia surveillance  Mandatory Clostridium Difficile surveillance  Orthopaedic Surgical Site Surveillance  Serious Hazards of Transfusion Local  ITU Outreach Nurses Audit  Resuscitation Audit  Pressure Ulcer Audit  Pharmacy Audits  Endoscopy Audit National  National Cardiovascular Disease Audits  National Sentinel Audit of Stroke  National Confidential Enquiry into Perioperative Outcomes and Deaths  National Tonsillectomy Audit  National Cancer Audits  National Joint Registry  National Blood Transfusion Service Audit  PAS  Claims records  Inquest records  Morbidity and Mortality Meeting Minutes  Case Notes An example of some sources relevant to medical and surgical inpatients

7. Issues to consider when choosing which data sources to use: What type of information is available? Incident Reporting Systems: equipment failures, medication incident, complications or delays related to diagnostic tests, admission/ discharge issues, falls Surveillance systems: infection control, blood transfusions, medication incidents Audit: clinical assessment and initiation of treatment issues, monitoring, problems related to treatments or procedures

8. Issues to consider when choosing which data sources to use: What type of information is available? 2 PAS: problems related to treatments and procedures, infection control Case notes: complications or delays in monitoring or treatment, discharge failures, medication errors, infection control Complaints: communication failures, admission/ discharge failures

9. Types of medication incident identified by different sources Data SourceExamples of incident detected Clinical Incidents Product: side effects Prescription: illegibility, incorrect dose, drug: drug interaction, prescription despite know allergy, failure to prescribe current medications Dispensing: delays in drugs reaching wards, patients discharged without TTAs Administration: wrong drug, wrong dose, wrong patient, administration despite know allergy, allergic reaction Monitor: failure to monitor side effects, toxicity Communication: failure to give instructions to patients Case NotesPrescription: illegibility, incorrect dose, drug: drug interaction, prescription despite know allergy, failure to prescribe current medications Administration: administration despite know allergy Monitor: failure to monitor side effects, toxicity ClaimsAdministration: administration despite know allergy Monitor: failure to monitor side effects, toxicity InquestDeaths following drug toxicity including renal failure and oversedation ComplaintsPrescription: failure to prescribe current medications, incorrect dose, drug:drug interaction or side effects Monitor: failure to monitor side effects, toxicity Committee on Safety of Medicines Drug side effects via the Yellow Card System AuditQuality of medical records audit: Can identify % case notes with allergy information recorded, % illegible entries in drug charts. Pharmacy Audit: e.g. % of medical errors detected by ward pharmacist

10. Contribution each data source made to identifying incidents falling into the different NPSA’s categories

11. Issues to consider when choosing which data sources to use: What type of information is available? Proportion of incidents in different harm grades for each data source, April 2004 to March 2005

12. Issues to consider when choosing which data sources to use: How is the information collected? Is it continuous or intermittent? How complete and detailed is the information about incidents? Are there significant delays in information reaching the source? How accessible is the information?

13. How can the Trust improve the quality of it’s patient safety information Increase frequency of incident reporting by staff Encourage collection of risk factor/ contributory factor information Ensure consistency of coding of types of incidents on LRMS Collect information from departmental incident reporting systems centrally Ensure Audit database is complete and up to date Provide time for staff to engage in retrospective case note review

14. An approach to exploring incidents related to infection control Infection control is a key issue in patient safety but remains under reported (0.9% of all reported incidents to the NRLS up to March 2005). Many Trust data sources collect information on infection control related incidents. Which data sources identify incidents in this category? 211 incidents were found across a single year on interrogation of the LRMS, a sample of case notes and PAS in a single acute Trust Other potential sources include local audits, microbiological surveillance systems and departmental local incident reporting systems

15. Percentage of infection control incidents found within each information source Source % of infection control incidents in that database Clinical Incidents4 Inquest5 Case notes (based on a sample of 220) 13 Complaints9 PAS39 Claims20

16. Do different data sources identify different subcategories of infection control incidents? Contamination of equipment/ failure to sterilise 0.9% of all IC incidents (100% of IC incidents found in the clinical incident database) Cross infection/ hospital acquired infection 55% of all IC incidents (90% of all IC incidents found in case notes, 50% in PAS and 38% in complaints ) Wound infection 10% of all IC incidents (11% of all IC incidents found on PAS) Treatment/ procedure inappropriate 1.4% of all IC incidents (13% of all IC incidents found in complaints) Unsafe/ inappropriate clinical environment 3% of all IC incidents (44% of all IC incidents found in complaints) Other 29% of all IC incidents (34% of all IC incidents found in PAS)

17. Do different data sources detect infection control incidents causing differing levels of patient harm?

18. Types of infection control incident identified by different sources Data SourceExamples of incident detected Clinical IncidentsMRSA positive patient admitted to clean surgical ward Failure to communicate information about MRSA between ward and theatre Lack of isolation room for TB patient Contaminated instruments in theatre Infected intravenous line ClaimsPost operative infection MRSA infection InquestPost operative infection leading to death ComplaintsCleanliness of hospital environment Staff not washing hands between patients Hospital acquired infection/MRSA Cannula left in situ on discharge Microbiological surveillance MRSA bacteraemia, C. difficile, GEC trends Surgical Site Surveillance: number of wound infections following knee and hip replacement Microbiology departmental reporting system Hospital outbreaks, microbiological environmental hazards

19. What can we learn about contributory factors? Analysis of the 9 infection control incidents found on review of 220 case notes revealed that the 60% of incidents occurred post procedure, 25% were related to poor catheter care and 25% related to failure to give antibiotic prophylaxis.

20. When to use this approach? To undertake an initial investigation of an area of concern To highlight the scope and scale of incidents related to known key risk areas e.g. medication incidents, patient misidentification incidents, incidents related to treatments or procedures To identify areas that would benefit from further assessment through methods such as audit or case note review

21. What can the Trust do to support such an approach? Leadership from senior management is essential to create a culture that promotes the sharing of information Incorporate this approach into clinical governance activities Identify and prioritise risk areas Identify relevant data sources Provide resources and support to departments to facilitate the collection, collation and analysis of information Ensure findings are shared across the organisation and further work is commissioned if required