1. A vision: using data to ensure the safe provision of care Dr Bruce Warner Deputy Director of Patient Safety NHS England

2. International and National Recognition of Patient Safety 2 1999 2000 2001

3. June 2012 – from the National Patient Safety Agency to the NHS Commissioning Board 2 “We propose to abolish the National Patient Safety Agency” “The work of the Patient Safety Division relating to reporting and learning from serious patient safety incidents should move to the NHS Commissioning Board… … covering the whole function from getting evidence to working up evidence-based safe services.”

4. Time to Move On NPSA Patient Safety Division Patient Safety Function to NHSCB(A) NRLS to ICHT 4

5. 5 Patient safety as an essential component of quality

6. 6 ““… [we all] need to place the safety of patients at the forefront of the agenda in healthcare. Safety cannot be allowed to play second fiddle to other objectives that may emerge from time to time. It is the first objective.” Sir Ian Kennedy, Chairman Healthcare Commission Patient experience Safety Effectiveness

7. Safety is not a minimum threshold – all services can and should strive to excellence in safety A. Why waste our time on safety? B. We do something when we have an incident C. We have systems in place to manage all identified risks D. We are always on the alert for risks that might emerge E. Risk management is an integral part of everything that we do PATHOLOGICALREACTIVEBUREAUCRATICPROACTIVEGENERATIVE The Manchester Patient Safety Assessment Framework

8. NHS Outcomes framework 8

9. The interplay between patient safety and clinical guidelines 9 It is about the way we safely deliver care once the clinical decision on how to treat has been made – the clinical decision may be the right one but it is not a given that we will deliver it without error.

10. NHS | Presentation to [XXXX Company] | [Type Date]10 Understanding the National Reporting and Learning System

11. 11 The National Reporting and Learning System (NRLS) Local Risk Management System Open Access E-Forms NHS net www The system collects all types of incidents from all care settings from all specialties from all staff groups

12. National Reporting & Learning System NHS Trusts Practitioners & Staff Patients Carers NRLS CQC MHRA NHS Complaints NHS Litigation Authority International Collaboration Australia USA Europe Standardised reporting Community Pharmacy multiples Commissioners

13. PATIENT SAFETY INCIDENT Any unintended or unexpected incident(s) which could have or did lead to harm for one or more persons receiving NHS funded care NO HARM LOW MODERATE SEVERE DEATH Not prevented, but resulted in no harm Prevented, not impacted on patient NRLS definitions Good Catch Good Luck!

14. 14 By 31 March 2012 7,070,261 reports had been reported. Approximately 3,700 incidents are reported to the NRLS per day. Around 94% of incidents cause low or no harm

15. 15 Chart 1: Proportion of incidents by care setting for incidents reported to the NRLS 2010/11 NRLS limitations: very little reporting from general practice

16. Patient safety incidents reported to the NRLS 16

17. All care settings: death and severe harm themes 2011/12 17

18. Searching by keywords: example 18 NICE Quality Standard for Bacterial meningitis and meningococcal septicaemia in children Key word search for ‘mening*’ in free text of incident reports identified 182 relevant incidents, all clinically reviewed and themes summarised to inform the development of the Quality Standard

19. We need a trigger

20. NHS | Presentation to [XXXX Company] | [Type Date]20 Different solutions for different problems

21. Unsafe acts Unsafe acts Unintended actions Intended actions Skill based errors Memory or attention failures Rule & Knowledge Based errors Routine Reasoned Reckless Malicious Violations Mistakes Slips & Lapses Education and training will not prevent slips and lapse or violations and we will constantly have new junior staff with knowledge gaps

22. Routine violations: campaigns to change culture and attitudes 22

23. Slips and lapses: make the right thing the easiest thing to do 23

24. Knowledge and rule based error: build in senior advice and empower patients 24

25. Patient Safety Reports for NICE QS

26. Local audit data PCT audit of vaccine storage in GP practices shared with NPSA Significant proportion of vaccines stored outside recommended temperature range NRLS Searched National guidance produced NHS | Presentation to [XXXX Company] | [Type Date]26

27. 27 Rapid but robust process: NRLS search Threshold criteria Literature search Topic expert advice Patient and carer perspective Formal consultation (100+) ‘Still safe and relevant?’ reviews

28. NHS | Presentation to [XXXX Company] | [Type Date]28 Last words

29. The power is in the qualitative data 29 “…called to A wing…prisoner in cardiac arrest….had attended healthcare unit yesterday complaining of indigestion, given Gaviscon, no access to previous health records (recent transfer), in hindsight probably missed diagnosis of acute coronary syndrome…….” “Terminally ill patient required switch to syringe driver as no longer able to take oral meds; only one community nurse on duty this Sunday for [large geographical area] and 17 urgent visits already on list; five hour delay causing much distress to patient and family”

30. Sepsis Report Whole report based on 10 case studies Power was not in the 37,000 deaths a year but in the human storey

31. Jill’s Storey

32. Wrong Patient

33. Thank you for listening bruce.warner@nhs.net bruce.warner@nhs.net