1. Sharing to Sustain – making PCT land a safer place! Peter Mansell & Maureen Baker NPSA March 9 th 2004

2. Three questions What information is going to be most useful to inform safer choices? How do we best involve users to improve patient safety? How can the NPSA complement the work of PCTs?

3. Context 4 - GP adverse events frequency medication - w rong drug - wrong dose - known allergy misdiagnosis minor surgery referral delayed diagnosis:- - malignancy, orthopaedics, infection 50% 5% 7% Sources: MDU Claims settled 1990-2000 15%

4. Sources of information What are some of the ways of engaging patients and the public about a safer choices? Complaints RCAsPatient Surveys Patient Forums NRLS Thematic reviews

5. Involving users for making things safer Providing information on safety performance of healthcare organisations and services –How do we guard against unintended outcomes? Jointly developing national patient safety goals/standards –Can we assure a core level of safety? Publishing data –What will be meaningful and not unduly erode trust? Working with patients on solutions –Decisions about when and how we involve people will always be difficult

6. Motivation to act Variation in quality exists and I may not get the best quality Failure to act will have a negative effect on health The harm that will result from failure to act: –is greater than any risk which is perceived to be associated with the action; –is greater than the burden of time and effort involved in taking action OPM/The Nuffield Trust Involving People in Public Disclosure of Clinical Data

7. Which is the safer organisation? Reported incidents per annum

8. Supporting Choice 7 steps to patient safety – developing tools to help you: 1.Build safer cultures 2.Lead and support your staff 3.Integrate your risk management activity 4.Promote reporting 5.Involve patients and the public 6.Learn and share safety lessons 7.Implement solutions

9. Discussion and Questions