Presentation on theme: "The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative."— Presentation transcript:
The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative
Severity of incidents by care setting, April 2006 to March 2007 Some facts and figures
Number of patient safety incidents reported, by quarter, 10/2003 to 9/2007
Reported incidents by type, July 2006 to June 2007
Care setting of incident reports July 2006 to June 2007
Reported degree of harm to patients, July 2006 to June 2007
The intervention - Working in Partnership with Patients
Patients For Patient Safety Part of the WHO Alliance for Patient Safety
Who are we? Susan Sheridan* Co-founder Consumers Advancing Patient Safety, USA (Chair) Peter Mansell* Director for Patient Experience and Public Involvement, National Patient Safety Agency, England and Wales Martin J. Hatlie President, Partnership for Patient Safety, USA Garance Upham* People's Health Movement, Disability and Economics Circle Jo Harkness Policy & External Affairs Director. International Alliance of Patients' Organizations Helen Hughes World Health Organisation (Secretariat) * = people who have experienced harm
The aim To generate: a patient centred approach in patient safety in health consumer interest and networks in patient safety in/with the Alliance’s work strands each other and apply a method of identifying patient safety champions
The Group’s role Defined in the statement of case 1.to help clinicians get the whole picture (we are often the only people who see this) and understand issues from a patient’s perspectives such as social and economic aspects 2.PFPS participating as equals; not victims. 3.We expect the spirit to be willing from professionals but default behaviours to mean we have to speak up!
Current work About 200 activists from around the world working Consumer champions’ workshops in WHO regions and within countries WHO regional offices developing patient safety strategies Solutions products Research developing tools to measure harm working with teams delivering studies The global patient safety challenge pilot sites guidelines content
The patient involvement landscape and experience within England
Reference points When things go wrong, [patients] and their families suffer from the harm caused. Such harm is often made worse by the defensive and secretive way that many healthcare organisations respond in the aftermath of a serious event. Partnership must be a key theme: patients, health professionals, policymakers and healthcare leaders should be working together to prevent avoidable harm in healthcare. A particular focus is to challenge the current culture of denial. (Safety First 2006)
Where can patients add value? Sharing their insights Offering different perspectives Using experience for improvement
Sharing insights - Anticoagulants Process stepsPatient experience and barriers to safe use Decision to treat Use of medical jargon and abbreviations unhelpful. Lay knowledge of warfarin is as “rat killer” and this use needs to be described in context of patient anticoagulation for some. Document and Communicate diagnosis and treatment plan Poor communication with carers. Stroke patients receive less information and support than others. No planning for coping during first four weeks post-discharge, nor for longer term regarding schooling, holidays, and other social events. Lack of information about effect of foods and alcohol on anticoagulation control. Overall discharge is the weakest yet critical stage. Prescribe Lack of communication between hospital consultant / clinic and GP when new drugs are introduced – other prescribers can be unaware of this. Conflicting information about aspirin; some are prescribed whilst others are told to avoid – the reasons for this need to be explained. Conflicting advice is a source of anxiety – patients do talk to one another and compare treatments. Monitor treatment Home testing appreciated by patients but not by clinicians.
Offering different perspectives - number of trusts that regularly report to the NRLS October 2003 to December 2007 - 2,145,606 PSIs Of the 427 NHS organisations in England and Wales,* 89% reported at least once between October to December 2007 57% of all NHS organisations didn’t report at least once per month
Using experience for improvement - views on medication – implications for commissioning Design Two people reported mistakes made in the use of insulin pens, (slow-release and a quick-release), which look identical. When one person was about to go hypoglycaemic, they picked up the slow- release pen by mistake and ended up in hospital. “This is easy to do when you’re in a hurry and anxious”.
Language, names and look of drugs Several participants described how a change in the brand of a prescribed drug can create serious problems, causing confusion and increasing the risk of mistakes being made Implications for the NHS in commissioning: Spot market purchase brings its own set of risks when viewed by patients Different look/Language/Names
So the impact of involving patients can be to Provide new knowledge New ways of seeing things.. and so.. Provide a way to reconnect with people who have lost trust
The NPSA contribution to you – making space for staff and patients* May workshop linked to the Patient Safety Congress To foster and build collaboration and links between patients and staff on the range of patient safety efforts at regional and local levels, so that lessons can be shared and partnerships created. Three summit events aimed at answering: What do safe health services look like? What do safe GP services look like? What do safe Mental health services look like? Autumn workshop aimed at SHA alliances/federations and patients to review work to date
Closing message Patient safety Can’t be achieved without the active involvement of patients and those close to them Is about trust and transparency as well as reducing error and harm Our role is to help staff and patients regionally and locally work together