Seven steps to patient safety A guide for NHS staff

1 Seven steps to patient safetyA guide for NHS staffSeven steps to patient safetyStep 1 Build a safety culture step 2 Lead and support your staffStep 3 Integrate your risk management activityStep 4 Promote reportingStep 5 Involve and communicate with patientsand the public step 6 Learn and share safety lessonsStep 7 Implement solutions to prevent harmCreating a common language for patient safetyPatient safety : the process by which an organisation makes patientcare safer. This should involve: risk assessment; the identification andmanagement of patient -related risks; the reporting and analysis ofincidents; and the capacity to learn from and follow-up on incidentsand implement solutions to minimise the risk of them safety incident:any unintended or unexpected incidentwhich could have or did lead to harm for one or more patientsreceiving NHS funded healthcare.

2 This is also referred to as an adverseevent/incident or clinical error, and includes near misses. Clinical governance:a framework through which NHS organisationsare accountable for continuously improving the quality of theirservices and safeguarding high standards of care by creating anenvironment in which excellence in clinical care will guide to patient safety4 patient safety - our starting point5 Seven steps to patient safety7 What can you do? step 1 Build a safety culture 9 Create a culture that is open and fairStep 2 Lead and support your staff 11 Establish a clear and strong focus on patient safety throughout your organisationStep 3 Integrate your risk management activity13 Develop systems and processes to manage your risks and identify and assess things that could go wrongStep 4 Promote reporting14 Ensure your staff can easily report incidents locally and nationallyStep 5 Involve and communicate with patients and the public 16 Develop ways to communicate openly with and listen to patientsStep 6 Learn and share safety lessons18 Encourage staff to use root cause analysis to learn how and whyincidents happen step 7 Implement solutions to prevent harm20 Embed lessons through changes to practice.

3 Processes or systemsThe local face of patient safety22A patient safety manager in your areaLooking to the future23 How do you measure your success in patient safety ?Bibliography 24 Find out more about patient safetyThis is an overview of the NPSA s detailed guide to good practicewhich covers building a safer culture and managing, reporting andlearning from patient safety incidents. Seven steps to patient Safetywill be available in full at from December you would like to receive future updates on the NPSA s work, andpatient safety news and events, you can subscribe to the NPSANewsLine via our web site. steps to patient safety : A guide for NHS staff |1 National patient safety Agency 20032| Seven steps to patient safety : A guide for NHS staff National patient safety Agency 2003 IntroductionEvery day more than a million people are treatedsafely and successfully in the NHS.

4 But theevidence tells us that in complex healthcaresystems things will and do go wrong, no matterhow dedicated and professional the staff . And when things go wrong, patients are at riskof effects of harming a patient are can be devastating emotional andphysical consequences for patients and theirfamilies. For the staff involved too, incidentscan be distressing, while members of theirclinical teams can become demoralised anddisaffected. safety incidents also incur coststhrough litigation and extra safety concerns everyone in the NHS,whether you work in a clinical or a non-clinicalrole. At the National patient safety Agency(NPSA) we believe that tackling patient safetyin the NHS collectively and in a systematic waycan have a positive impact on the quality ofcare and efficiency of NHS we need your help to make this steps to patient safety : A guide for NHS staff |3 National patient safety Agency 2003 Your guide to patient safetyThis summary guide has been produced toprovide you with an overview of patient safetyand to update you on the tools the NPSA isdeveloping to support you.

5 The NPSA was set up in July 2001 following recommendations from theChief Medical Officer in his report on patient safety , An Organisationwith a Memory 1. Its role is to improve the safety of patients bypromoting a culture of reporting and learning from patient safetyincidents. By incidents we mean times when things go wrong in theNHS that did or could have harmed a patient . The National Reportingand Learning System (NRLS) on patient safety incidents will be central to our strategy. Data collected through the system will help us to: identify trends and patterns of avoidable incidents, and underlying causes; develop models of good practice and solutions at a national level; improve working practices in NHS organisations locally throughfeedback and training; and to support ongoing education and patient safety depends not only on our work nationally, butalso on the vital work that is taking place at a local level.

6 Since we wereestablished in 2001, we have encountered a high level of commitmentto patient safety from a diverse range of NHS and non-NHS of organisations are already working with us to driveforward the patient safety hope this guide helps you identify the gains you can make withinyour own organisation, department or team. To assist you locally wehave appointed a network of 31 patient safety managers acrossEngland and Wales. See page 22 for more on what the manager inyour area can offer in healthcare is a relatively young field internationally and it willbe some time before we understand its full potential. We still have along way to go. However, we are already seeing evidence that byworking together we can all make healthcare safer. Sue Osborn and Susan WilliamsJoint Chief Executive4| Seven steps to patient safety : A guide for NHS staff National patient safety Agency 2003 Improving patient safetydepends not only on ourwork nationally, but also onthe vital work that is takingplace at a local level.

7 Sincewe were established in2001, we have encountereda high level of commitmentto patient safety from adiverse range of NHS andnon-NHS staff . We hope this guide helpsyou identify the gains youcan make within your ownorganisation, departmentor safety - our starting pointThe National patient safety Agency (NPSA) was formed following the publication of two reports on patient safety in the NHS, AnOrganisation with a Memory(Department of Health, 2000), and itsfollow-up Building a Safer NHS for patients (Department of Health,2001) 2. The reports exposed the need to learn more from things thatgo wrong and mobilised the patient safety movement in the NHS. They highlighted research which suggested that around 10% ofpatients admitted to UK acute hospitals suffer some kind of patientsafety incident, and that up to half of these could have beenprevented.

8 Findings in the US, Australia, New Zealand and Denmarkhave suggested similar error rates. It is estimated that over 850,000 incidents either harm or nearly harman NHS hospital inpatient in the UK each year, with 44,000 of theseincidents proving fatal of which half were preventable. This means thaton average 40 incidents a year contribute to patient deaths in a singleNHS organisation. Although most of the research to date has focusedon incident rates in acute care, many of the underlying contributoryfactors also apply to other healthcare have also shown that the best way of reducing error rates isto target the underlying systems failures, rather than take actionagainst individual members of staff . It is vital that we confront twomyths that still persist in healthcare, as identified by Dr Lucian Leape 3from the Harvard School of Public Health: the perfection myth: if people try hard enough, they will not makeany errors; the punishment myth: if we punish people when they make errors,they will make fewer of the NPSA, we recognise that healthcare will always involve risks.

9 But that these risks can be reduced by analysing and tackling the rootcauses of patient safety incidents. We are working with NHS staff andorganisations to promote an open and fair culture, and to encouragestaff to inform their local organisations and the NPSA when thingshave gone wrong. In this way, we can build a better picture of thepatient safety issues that need to be addressed. At a local level healthcare staff can use this information to help avoidfuture risks. Nationally, the NPSA can identify underlying trends thatrequire an NHS-wide response. In short, we believe it is no longerenough to rely on the best efforts of NHS staff to provide high quality,safe care; we must improve the systems they operate in and supportthem in their work. Seven steps to patient safety : A guide for NHS staff |5 National patient safety Agency 2003It is estimated that over850,000 incidents eitherharm or nearly harm anNHS hospital inpatient inthe UK each year, with44,000 of these incidentsproving fatal of which halfwere clinical governance agendahas provided the NHS with agreater focus on patient safety than ever before.

10 It has helped NHSorganisations develop clearer lines of accountability, strengthen theirrisk management functions, and improve their methods of assessingclinical quality. The new Commission for Healthcare Audit andInspection (CHAI) will continue this drive for radical improvements in the quality and efficiency of our healthcare from April the clinical governance framework, two key NPSA initiativeswill drive the patient safety agendaforward:1 During 2004 the NPSA will roll out a National Reporting andLearning System (NRLS)across NHS organisations in England andWales. This is the most ambitious patient safety incident data collectionsystem in the world. It will directly inform the development of ourpatient safety solutions and future research, and will help the UKremain at the forefront of patient safety parallel the NPSA will provide specialist training on Root CauseAnalysisto staff in NHS organisations that begin reporting technique is used to investigate incidents in a thorough andrigorous way, and the training will support local learning and promote aconsistent approach to managing incidents across the service.