Select Committee on Health Written Evidence

Memorandum by the National Patient Safety Agency (NPSA) (PS 39)



  1.  Over the past 60 years, the NHS has evolved to meet the growing needs of its patients. Advances in technology, the development of new services and increased complexity of treatments bring both opportunity and risk. The healthcare that heals us can also sometimes harm us. On average, around 10% of admissions to hospitals worldwide are associated with some sort of unintended harm to patients. Over the past decade our understanding of this challenge has grown and patient safety is now seen as a core focus for many health systems worldwide.

  2.  The National Patient Safety Agency (NPSA) was established in 2001 to lead and support the NHS to improve patient safety, in particular through managing a national patient safety incident reporting system. The Agency has significantly re-focused over the past 18 months. Lessons from incident reports are now being actively used to provide patient safety recommendations, advice and feedback to the NHS in England and Wales. This includes:

    —  Better detection and understanding of risks to patients when serious harm or death is reported

    —  Targeting patient safety recommendations and advice for the NHS on risks and hazards and practical strategies for addressing these at a local level

    —  Working with senior clinicians to develop and implement safer practices within specific speciality areas eg in maternity, anaesthesia, radiology and neonatology

    —  Closer working with regulators to embed patient safety in national standards and assessment of services

    —  Working towards more specific guidance which is "implementation ready"

  3.  Healthcare can be safer. Action is needed both nationally and locally to make patient safety the top priority at every level of the NHS. Strong and visible leadership is essential. Timely implementation of safer practices is a continuing challenge.

  4.  The NPSA asks the committee to consider the following recommendations:

    —  Boards, senior managers and senior clinicians need to demonstrate that patient safety is their top priority

    —  All NHS organisations should have robust systems for reporting incidents locally and nationally. Importantly these should lead to learning and action. The response system is always more important than the reporting system

    —  All NHS organisations should have local strategies to ensure quicker implementation of safer practices where important risks have been identified

    —  The new regulator, the Care Quality Commission, should maintain and build the focus on patient safety achieved by the Healthcare Commission

    —  Every primary care trust commissioner should make patient safety a key aim of commissioning


  5.  The Department of Health published An Organisation with a Memory[213] in 2000. It recommended the establishment of an Agency, within the NHS, that would create a national reporting system enabling patient safety incidents to be analysed and evaluated by clinical specialists. Best practice guidance would be distributed back to the service for local implementation. As a result, the NPSA was established. It covers both England and Wales and now includes; the National Reporting and Learning Service, the National Clinical Assessment Service, the National Research Ethics Service and an oversight role for the three Confidential Enquiries. Details are shown in Annex 1.

  6.  This submission addresses points 1, 2b, 2c, 2d and 3 of the terms of reference of the Inquiry.

Q1.   What are the risks to patient safety and to what extent are they avoidable?

  7.  The top ten risks to patient safety are:

    —  Variable leadership from Boards, senior clinicians and senior managers

    —  A blame culture which drives problems underground

    —  Defensive communication with patients and their families when things go wrong

    —  Limited patient safety education for staff in their basic training

    —  Not enough emphasis on building high performing frontline teams

    —  A reactive approach to risk meaning that hazards are not identified before they lead to patient harm

    —  A superficial approach to incident investigation which often fails to identify the underlying causes and system weaknesses

    —  Inadequate standardisation of equipment and processes causing unsafe variability

    —  Patchy and slow implementation of safer practices in frontline services

    —  Not harnessing technology as a powerful tool for protecting patients against harm

  8.  The national reporting and learning system (NRLS) managed by the NPSA collects patient safety incident reports (defined in annex 4) from staff in all NHS organisations. A total of 2.5 million reported incidents since late 2003 to date. Over 70,000 incidents are reported monthly. The NRLS is an increasingly mature data system which is unique in the world for its scope and comprehensiveness.

  9.  Chart 1 shows the rise in reporting as organisations have been connected to the system and the progressive improvement in the reporting culture within the NHS. This is a positive development as high reporting is usually associated with a stronger patient safety culture.[214]

Chart 1. Number of incidents reported from October 2003 until end June 2008 together with the percentage of trusts reporting at least once in a quarter.

  10.  The majority of incidents reported to the NRLS come from acute hospitals (over 70%). Incident types include patient falls (around 30% of reported incidents), incidents related to treatment and procedures (11%) such as marking the wrong site for an operation, drug incidents (9%) such as prescribing or administering the wrong amount, and incidents related to the use of equipment (3%).

  11.  The level of harm of each incident is coded locally. The percentage of incidents which lead to death are less than 1% with the vast majority of incidents reported as not causing harm to patients. The range is shown below[215],[216] :

    —  66% (n=563,224) are reported as no harm

    —  27% (n=229,274) are reported as low harm

    —  6% (n=52,173) are reported as moderate

    —  1% (n=7,660) are reported as severe

    —  Less than 1% (n=3,471) are reported as death

  12.  There have been fewer studies, and limited number of incidents reported to the national reporting system, from outside of acute care settings, so the size and scope of the problem in primary care is not yet fully understood. The NPSA is working with primary care trusts to address under-reporting. Examples of the primary care incidents are; missed or wrong diagnosis, missing results and poor follow up.

To what extent are they avoidable?

  13.  Lessons from other industries and patient safety research[217] are:

    —  Healthcare will never be completely risk free

    —  A systems approach focuses on the conditions under which individuals work rather than blaming individuals

    —  Risks are avoidable depending upon the extent to which they are identified and managed

    —  Managing risk involves the balance between the potential for harm, the likelihood of doing good and the choices available at the time

    —  High reliability organisations which manage their risks well have learned the knack of preventing a minor risk from becoming a major incident, they are successful because they expect things to go wrong and design their organisational processes so they detect risks quickly

    —  There is much that health care can learn form other high risk industries which have made the transition to high reliability

Q2.   What is the current effectiveness in ensuring patient safety?

  14.  The NHS has made good progress over the past decade in improving the overall quality of care for patients[218]. Moderate progress has been made in patient safety including

    —  Greater awareness and understanding of the systems approach to patient safety and the limitations of blaming people when things go wrongs are made

    —  More is known about the type of patient safety problems across the NHS largely through improved incident reporting

    —  Increased knowledge about practices which systematically improve patient safety

    —  Growing number of organisational and team examples of good practice in patient safety but this is not widespread

  15.  Less progress has been made in:

    —  Providing visible leadership by senior clinicians and senior managers

    —  Ensuring patient safety is equal in importance to finance and activity in the work of Boards

    —  Proactively managing risk before patients are harmed

    —  Educating and engaging all clinical staff on patient safety

    —  Understanding and tapping into the perceptions and knowledge of patients and their families

    —  Implementing learning from incident reports quickly in ways that lead to lasting change

    —  Using design to improve safety and reliability in healthcare; the world of design has a lot to offer health care which lags behind other high risk industries in systematically applying design principles to safety


  16.  The NPSA leads and supports the NHS to improve patient safety by:

    —  Using national data to detect and understand sources of risk by spotting clusters of incidents arising from individual reports that are not often identified until data are analysed at a national level

    —  Identifying the most urgent risks by reviewing all serious incidents and deaths and providing action points

    —  Alerting the NHS to the potential for harm quickly by providing recommendations advice and guidance to ensure the right information gets to the right person eg rapid response reports such as the risk of confusion between different drugs with similar names or the risks from using specific equipment

    —  Extracting learning by identifying key trends and patterns in incident reports and providing analysed feedback eg online quarterly data summaries, safety topic reports and benchmark data to each NHS organisation

    —  Identifying safer practices which reduce risks and harm by aggregating data (incidents, claims, investigations, complaints, research) and developing targeted clinical guidance eg falls prevention, care of deteriorating patients, medication safety guidance, jointly with the Royal College of Nursing, fact sheets on patient nutrition in hospitals and improving hand hygiene

    —  Making implementation as easy as possible by designing toolkits and training packages in areas such as incident investigation, patient safety culture, risk factors and risk assessment, and Seven Steps to Patient Safety

    —  Partnerships with senior clinicians to help them implement safer practices eg in maternity, anaesthesia, radiology and neonatology

    —  Using technology, design and human factors to "design out" problems eg design of ambulances, resuscitation trolleys, labelling and packaging medicines, hospital pharmacies and medical devices

    —  Working with regulators and commissioners to embed patient safety in national standards and commissioning of services

    —  Evaluating the uptake and impact of solutions and re-issuing previous guidance where necessary

  17.  A full list of all outputs is shown in Annex 2, examples of the most recent are described below:

Table 1 Examples of NPSA outputs

Date issued Topic, type of advice and recommendations
11 Aug 2008Vinca Alkaloid Minibags Rapid Response Report There have been reports of fatal and serious incidents from hospitals outside the UK in which doses of Vinca alkaloids intended for venous administration have been administered by the intrathecal (spinal) route instead. Previous guidance to the NHS in England and Wales was to dilute doses of Vinca alkaloids to 10ml or greater in a syringe (rather than administer it in its concentrate form) in order to reduce the risk of wrong route incidents. This guidance has been updated following the learning from these incidents in other countries. The rapid response report recommends that doses of Vinca alkaloids should be prepared and administered in intravenous Minibags to further minimise the risk of wrong route incidents.
2 Sep 2008Hand hygiene Patient Safety Alert Significant improvement has been made in hand hygiene practice over the last four years. The reduction in MRSA bacteraemia can in part be attributed to the concerted action across the NHS. However, to maintain this and other improvements it is vital that hand hygiene remains high on the patient safety agenda. The Alert highlighted: The role of hand hygiene by healthcare staff in preventing and controlling infection The point of care as the crucial moment for hand hygiene The appropriate placement of alcohol handrub products Which hand hygiene products to use and when The current recognised standard for hand hygiene products Management of risks including ingestion, storage and skin
18 Sep 2008NHS Number Safer Practice Notice Mis-identification is a known risk in healthcare. Using the NHS Number as the national patient identifier; (or the NHS Number in conjunction with a local hospital numbering system) can reduce the number of times patients are wrongly identified. The Notice recommends: Using the NHS Number (and its bar-coded equivalent) in/on all correspondence, notes, patient wristbands and patient care systems to support accuracy in identifying patients and linking records Putting processes in place to ensure that patients can know their own NHS Number and are encouraged to make a note of it (for example through patient literature that explains the NHS Number, its uses and advantages, and how patients can use it to increase safety) Reinstate medical record cards and use as a means of informing patients about their NHS Number and encouraging them to use it where appropriate.

  18.  Currently the NPSA evaluates guidance through:

    —  Self reports by Trusts through the Safety Alert Broadcast System (SABS) in England

    —  Surveys in Wales

    —  Monitoring incidents reported to the national system

    —  In-house and commissioned research

  19.  For example, the Agency detected incidents related to the mis-placement of naso-gastric tubes and issued guidance in February 2005. To assess implementation of the guidance, a review of incidents between August 2005 and February 2008 was undertaken. The findings below were highlighted in the quarterly feedback report issued to the NHS in August 2008:

    —  210 related to nasogastric tube placement

    —  clear awareness of the risks of tube misplacement

    —  compliance with the alert was fair with some indications of a failure to implement existing advice consistently

Chart 2 Example of analysis conducted by the Agency.

  20.  Quicker and more reliable implementation of risk reduction strategies and safer practices are two major challenges. This needs local action with support from the NPSA. Key strategies include:

    —  Understanding the factors which help and hinder implementation

    —  Revisit and update safety advice and recommendations that have not yet been fully implemented

    —  Develop new approaches and tools to support local implementation eg Never Events

    —  Improve communication and dissemination strategies to ensure the learning is clear and actionable

  21.  The NPSA has supported national policy recommendations by implementing those made in Safety First and High Quality Care for All. Detail on implementation is shown in Annex 3. In summary the NPSA has:

    —  Supported national patient safety campaigns in England and Wales

    —  Improved the national reporting and learning system to make it easier to report, provided more responsive feedback and alerted the NHS quickly about areas of risk which require addressing

    —  Worked in partnership with SHAs to transfer the NPSA remote workforce to establish regional patient safety action teams and further embed patient safety in the local management of the NHS

    —  Developed improved tools for investigating incidents

    —  Promoted the importance of the role of the Board and leaders through education of Non Executive Directors as part of the Appointments Commission Induction programme

    —  Worked closely with other national bodies

    —  Continued to promote "Being Open" with patients

    —  Recruited 22 Patients for Patient Safety Champions for England and Wales

    —  Developed a list of evidence based practices that if effectively implemented should mean that certain incidents never happen (never events) for primary care commissioners to use as patient safety indicators

    —  Set up a national initiative to implement best practice interventions that has been shown to work in other parts of the world ie reducing central line infections in adult ICUs

    —  Developed Patient Safety Direct to make it much easier for staff to report incidents to the NPSA

Q3.   What should the NHS do next regarding patient safety?

  22.  NHS organisations, Boards and leaders need to:

    —  Make patient safety a higher priority for all who work in the NHS

    —  Give patient safety the same attention as activity targets and finance

    —  Provide visible leadership for building a stronger safety culture

    —  Strive to achieve a high level of organisational reliability

  23.  Incident reporting at a local and national level is vital in understanding the type of safety problems which need action and to set priorities. There is the need for a renewed focus on improving local risk detection and management systems. A continued focus on improving reporting to the national reporting and learning system is also important, particularly for serious incidents.

  24.  A key area which requires concerted effort by NHS organisations is quicker implementation of learning which reduces risks to patients. The amount of guidance produced each week in the NHS makes it hard for organisations to prioritise. Also, the amount of evidence for an individual clinician is overwhelming, and it is unrealistic for a clinician to be able to embed this into their daily clinical practice without support. This requires national and local organisations to develop strategies to support implementation of safer practices.

  25.  The new Care Quality Commission should continue to place a high emphasis on patient safety. Strong partnerships should be forged with the NPSA to incorporate effective methods of monitoring patient safety and ensuring compliance with recommendations arising from safer practice guidance, incident reports and investigations. This will build on the work of the Healthcare Commission.

  26.  Commissioners should include explicit patient safety requirements alongside cost and volume requirements when commissioning services. They should receive and review information from healthcare providers about their safety culture, learning from incidents and achievements in implementing safer practices.


    —  Boards, senior managers and senior clinicians need to demonstrate that patient safety is their top priority

    —  All NHS organisations should have robust systems for reporting incidents locally and nationally. Importantly these should lead to learning and action. The response system is always more important than the reporting system

    —  All NHS organisations should have local strategies to ensure quicker implementation of safer practices where important risks have been identified

    —  The new regulator, the Care Quality Commission, should maintain and build the focus on patient safety achieved by the Healthcare Commission

    —  Every primary care trust commissioner should make patient safety a key aim of commissioning

National Patient Safety Agency

September 2008

Annex 1

National Patient Safety Agency Directions

    (a)  to co-ordinate systems wide patient safety functions by promoting a culture of reporting and learning from adverse events;

    (b)  to devise, implement and monitor a reporting system based on relevant national standards issued by the Department of Health regarding adverse events and near misses to promote a culture of reporting and learning;

    (c)  to collect and appraise information on reported adverse events and near misses and other material useful for any purpose connected with the promotion of patient safety;

    (d)  to provide advice and guidance useful in the maintenance and promotion of patient safety, clinical assessment, English NHS Research Ethics Committees and the patient environment and to monitor the effectiveness of such advice and guidance;

    (e)  to promote research which the Agency considers will contribute to improvements in patient safety, clinical assessment and the patient environment and to facilitate research which the Agency considers will contribute to improvements in English NHS Research Ethics Committees;

    (f)  to report to and advise Ministers on matters affecting patient safety, clinical assessment, English NHS Research Ethics Committees and the patient environment;

    (g)  to publish information relating to the exercise of its functions;

    (h)  to support NHS bodies who are concerned about the performance of an individual practitioner;

    (i)  to issue good practice and other guidance for the handling by NHS bodies of cases of poor performance on the part of practitioners in relation to—

    (i)  the NHS services which such practitioners provide, or

    (ii)  the NHS services which they assist in providing;

    (j)  to determine who may refer practitioners to the Agency or other bodies acting on its behalf for the purposes of assessment and to determine the criteria for the making of such referrals and for their acceptance by the Agency;

    (k)  to provide advice, support and agree action plans in relation to practitioners referred to the Agency;

    (l)  to determine criteria, methods and procedures for the carrying out of assessments and related activities and for the drawing up of action plans;

    (m)  to carry out assessments and related activities or to arrange for other persons to carry out any of those functions on its behalf;

    (n)  to monitor the diversity of practitioners referred to the Agency;

    (o)  in liaison with the Medical Royal Colleges and Faculties, specialist societies, those with general practice interests and any other interested parties whom the Agency may decide to consult, to establish and maintain lists of professional and lay persons who are authorised to carry out assessments in whole or in part ("authorised assessors");

    (p)  in relation to assessments carried out by the Agency, to appoint one or more authorised assessors (whether as employees or contractors of the Agency) to carry out the assessments;

    (q)  to arrange, or approve, training for authorised assessors or for those who wish to become authorised assessors;

    (r)  to review the carrying out of assessments and related activities by the Agency and other persons on its behalf in order to ensure consistency in the way in which assessments are carried out and in the contents of reports, recommendations and action plans, and to ensure compliance with legal obligations;

    (s)  to work in partnership with and to liaise with the General Medical Council, the General Dental Council and the Healthcare Commission in developing policies to ensure that overlap between the respective activities of these bodies and of the Agency is kept to a minimum and that effective channels of communication exist at both national and local levels;

    (t)  to consider possible improvements in relation to the assessment by an NHS body of the clinical performance of practitioners in connection with the provision of NHS services;

    (u)  to respond to requirements of the Secretary of State for Health including—

    (i)  establishing and operating effective alert systems and associated databases;

    (ii)  assisting in resolving suspensions and exclusions by NHS bodies of practitioners,

    (iii)  providing advice to NHS bodies who are considering the suspension or exclusion of a practitioner,

    (iv)  developing and administering the national suspensions and exclusions monitoring and reporting project, and

    (v)  providing advice to NHS bodies in respect of the application of conduct and capability procedures;

    (v)  to identify, in such areas of health care as may be notified by the Secretary of State, patterns of practice or service provision in the health service that appear to them to be causally related to unexpected or serious adverse outcomes and thereafter to make recommendations for good practice arising there from, including responsibility for ensuring the separate and effective management of the four National Confidential Enquiries;

    (w)  to work and liaise with the Department of Health in the development of delivery and educational programmes in relation to the operational components of improving hospital food and related nutrition;

    (x)  to work and liaise with the Department of Health in the development of delivery and educational programmes in relation to the operational components of improving hospital cleaning;

    (y)  to support the Department of Health in relation to design safety in healthcare facilities through—

    (i)  contributing to the Department of Health's development and production of relevant design guidance and standards,

    (ii)  undertaking specific projects relating to design safety which will contribute to the Department of Health's design policy development and strategy, and

    (iii)  providing a communication strategy for disseminating design safety information to the NHS including working with partners identified by the Department of Health who are associated with design safety issues; and

    (z)  to provide advice and assistance to English NHS Research Ethics Committees.

  (2)  In addition to the functions in paragraph (1) the Agency may—

    (a)  consider, and where appropriate, endorse guidance issued by other bodies concerning patient safety, clinical assessment and, with the approval of the Department of Health, the patient environment;

    (b)  with the approval of the Secretary of State, set local or national goals for improvements in patient safety, clinical assessment, the systems supporting research ethics committees and the patient environment;

    (c)  in relation to an assessment which it carries out under paragraph (1)(m), refer the practitioner the subject of the assessment to another body for particular tests or procedures notwithstanding that the individual who is to carry out the tests is not an authorised assessor; and

    (d)  in relation to an assessment which is to be carried out by another person on its behalf pursuant to arrangements made under paragraph (1)(m), include provision in those arrangements to the effect that that other person may make such a referral.

  (3)  In exercising the functions in paragraphs (1) and (2) the Agency shall have regard to the following factors—

    (a)  any guidance from the Secretary of State on the resources likely to be available to the NHS and any other relevant guidance from the Secretary of State; and

    (b)  the effective use of available resources.

  (4)  The Agency must obtain the consent of the Secretary of State to the issue of any good practice and other guidance and to the determination of any criteria, methods or procedures developed by the Agency.

Annex 2

Outputs from the National Patient Safety Agency since 2001


  As part of its implementation of Safety First the NPSA is working to provide a faster way for NHS organisations to report their most serious patient safety incidents to us. Rapid Response Reports are a "rapid reporting" facility to enable the NPSA to identify serious risks and problems that could be common across a number of NHS organisations more quickly.

Table 1  10 Rapid Response Reports

Date issuedTopic Description
11 Aug 2008Vinca Alkaloid, minibag Using Vinca Alkaloid Minibags (adult/adolescent units)
28 July 2008Infusions, arterial lines Problems with infusions and sampling from arterial lines
4 July 2008Opioid medicines Reducing Dosing Errors with Opioid Medicines
19 May 2008Chest drain, chest tube Risks of chest drain insertion
24 April 2008Intravenous, IV, Heparin Flush Risks with Intravenous Heparin Flush Solutions
22 Jan 2008Oral anti-cancer medicines Risks of incorrect dosing of oral anti-cancer medicines
26 Nov 2007Paraffin skin products Fire Hazard with Paraffin Based Skin Products
10 Sep 2007Haemorrhage Dealing with haemorrhage
3 Sep 2007 Injectable amphotericin Risk of confusion between non-lipid and lipid formulations of injectable amphotericin
18 June 2007Cytarabine Risk of confusion between cytarabine and liposomal cytarabine (Depocyteð®ñ)


  Prior to Safety First, information which was considered important to take urgent action on was disseminated via the safety alert broadcast system and labelled a patient safety alert.

Table 2  16 Patient Safety Alerts

Date issuedTopic Description
Hand hygieneRe-issue of patient safety alert—to emphasis the point of care for hand hygiene
27 Aug 2008Ventilator associated pneumonia in adults Jointly with NICE—Technical patient safety solution for ventilator associated pneumonia in adults
28 Mar 2007 Intravenous infusions in children Reducing the risk of low sodium when administering intravenous infusions to children
28 Mar 2007Epidural injections and infusions Safer practice with epidural injections and infusions
28 Mar 2007 Injectable medicines Promoting safer use of injectable medicines
28 Mar 2007 Liquid medicines Promoting safer measurement and administration of liquid medicines via oral and other routes
28 Mar 2007 Anticoagulants Actions that can make anticoagulant therapy safer
1 Jun 2006Oral methotrexate Improving compliance with oral methotrexate
18 Aug 2005 Naso and orogastric tubes Reducing the harm caused by misplaced naso and orogastric feeding tubes in babies under the care of neonatal units
2 Mar 2005 Correct Site Surgery Correct Site Surgery guidance
22 Feb 2005 Nasogastric tubes Advice to the NHS on reducing harm caused by the misplacement of nasogastric feeding tubes
30 Nov 2004 Methotrexate Update on Methotrexate usage
15 Sep 2004Spinal injuries Improving the safety of patients with established spinal injuries in hospital
2 Sep 2004 Clean hands Clean hands helps to save lives
29 Jul 2004 Methotrexate Methotrexate safety
18 Feb 2004 Crash Call Crash Call: standardisation of the number
6 Nov 2003 Potassium chloride Update on the implementation of recommended safety controls for potassium chloride in the NHS
23 Jul 2002Potassium chloride Reducing use of Potassium chloride concentrate solutions


  Patient Safety Notices were issued as good practice guidance to implement over time.

Table 3  Patient Safety Notices

DateTopic Description
18 Sep 2008NHS Number Promoting the use of the NHS number to reduce identification risks
3 April 2008Blood transfusions Update on "Right patient, right blood" Competency Assessment: timescales extended
3 Jul 2007 Wristbands: Patient ID Standardising wristbands improves patient safety
26 Feb 2007 Bedrails Using bedrails safely and effectively
5 Feb 2007 Radiology Improving radiology reporting
10 Jan 2007 Cleaning Colour coding hospital cleaning materials and equipment
9 Nov 2006 Blood transfusions Right patient, right blood—advice for safer blood transfusions
25 May 2006 Morphine and diamorphine Risks with high dose morphine and diamorphine injections
22 Nov 2005 Patient Identification Safer Patient Identification by using wristbands—right patient—right care
15 Sep 2005 Disclosure / Being Open Being open when patients are harmed
29 Apr 2005 Repevax and Revaxis Safer practice with Repevax and Revaxis vaccines
20 May 2004 Infusion device Improving infusion device safety
2004Spinal cord lesions Improving the safety of patients with spinal cord lesions (bowel care)


  Patient Safety Information was disseminated as good practice guidance for people to review their current practice against. These were generally reminders of existing guidance

Table 4  Patient Safety Information

Date issuedTopic Description
26 May 2005Latex allergy Protecting people with allergy associated with latex
15 Apr 2005Vaccination Vaccine incident—Review of a clinical incident in a PCT
7 Mar 2005Tracheostomy Improving emergency care for patients who breathe through their neck


  Patient Safety Guidance takes many forms, discussion documents, triangulation of the NRLS data with other data sources on a particular topic (patient safety observatory reports), toolkits, eLearning and so on.

Table 5abc  Patient Safety Guidance, tools and resources

A.  Thematic Reports

  Building a memory—Building a memory: preventing harm, reducing risk and improving patient safety

Mental health—Observatory Report: What can harm mental health patients, and what can prevent harm

  Safety in Doses—Observatory Report: Medicines-related patent safety incidents, and actions to prevent harm

  Slips Trips and Falls—Observatory Report: Analysis of inpatient falls, and recommended prevention

  Safer Care for the Acutely III Patient—Observatory Report: Analysis of factors causing harm to very ill patients, and guidance on best standards of care

B. Toolkits and Training Packages

  Foresight Training Resource Pack

  Hospital at Night —Tools to risk assess hospital care at night

  Being open when patient are harmed: an e-learning toolkit

  Guidance and tools on reducing harm caused by the misplacement of nasogastric feeding tubes

  Hospital hydration best practice toolkit

  Infection control: learning through action to reduce infection

  MaPSaF: a tool to help NHS organisations (bespoke guides for acute, ambulance, mental health and primary care) assess progress in developing a safety culture

  Root Cause Analysis and incident investigation toolkit

  Seven steps to patient safety: a comprehensive guide and toolkit

  Teamworking: measurement and development tools

  The incident decision tree: an interactive web based tool for NHS managers and organisations dealing with staff who have been involved in incidents

  The hospital at night (HaN) tools

  Out of hours risk assessment tools

  Maintaining patients on anticoagulants: an e-learning module; Starting patients on anticoagulants: an e-learning module

C.  Guidance

  Commissioning for patient safety for practice based commissioners

  Hand hygiene—cleanyourhands—The NPSA's campaign to promote hand hygiene

  Dysphagia—Best practice guidance to care for people who have problems in swallowing.

  Patient identification—Information and guidance on ensuring the right patient receives the right care

  Design guidance—Medication packaging; Pharmacy Dispensing Environment; Ambulances; Resuscitation trolleys; Environments including hospitals and single rooms

  Engaging clinicians: a resource pack including medical error a book of case stories

  Paraffin Fire Hazard leaflet and poster

  Patient Safety 2004 and Patient Safety 2006—national conferences and DVDs

  Risk assessment made easy

  Please Ask—guidance for patients

  Patient Safety Bulletins

  Creating the virtuous circle—creating an open and fair culture

  Patient Safety Induction Video

  Safety First—one year on

Annex 3

National Policy Recommendations

Table 1  Achieving Recommendations Safety First

NoRecommendation Progress
3The National Patient Safety Forum should oversee the design and implementation of a national patient safety campaign-focused initiative. The objective of this initiative should be to engage, inform and motivate clinical staff and healthcare providers o address the challenge of providing safer healthcare The NPSA in partnership with the NHS Institute for Innovation and Improvement and The Health Foundation designed a patient safety campaign strategy. There is now a Campaign Director, team and advisory group. The campaign uses the social movement methodology and was launched at the NHS Confederation Annual Conference 19th June 2008. Almost 200 Trusts have signed up to its cause and aim. There is now: A website which provides access to Campaign information and a discussion forum for the wider Campaign community. Intervention "how-to" guides containing the evidence base and suggestions for how to make improvement A range of learning events which will be available free of charge to registered organisations
4The role of the National Patient Safety Agency (NPSA) should be refocused on its core objective of collecting and analysing patient safety data to inform rapid patient safety learning, priority setting and coordinate activity across the NHS. A number of current functions, for example the development of technical solutions to improve patient safety, presently delivered by the organisation should in future be commissioned from other expert organisations with the requisite expertise. The NPSA has reviewed its NRLS strategy, vision, goals and objectives and has started to put in place significant changes in order to improve the collection and analysis of patient safety data. This includes systems for rapid collection and rapid learning. Since Safety First it has also worked with NICE to develop approaches to technical solutions. Due to the positive progress the NPSA has been informed that it will continue to develop and disseminate solutions to improve patient safety.
5The core purpose of the National Reporting and Learning System (NRLS) should be to identify sources of risk and harm to patients which can be acted upon at local and national level. The present NRLS should be redesigned to make it more effective in this respect, including simplifying and encouraging reporting as well as including a new category of analysing risk prone situations and anticipating adverse events. PCTs should take account of the information and learning available locally from the NRLS in commissioning services. Progress so far includes piloting rapid reporting of incidents, developing speciality reporting in some areas, introducing urgent response to certain types of issues and redevelopment of other NPSA products. The updated NRLS strategy includes a number of additional steps for system improvement. NPSA is working with the World Class Commissioning team at DH and primary care commissioners to develop indicators to improve safety through commissioning. The NPSA is leading on a project to develop "never events" as key indicators for commissioners to monitor.
6The Patient Safety Management function currently delivered by the NPSA should be hosted by Strategic Health Authorities (SHAs), and recast as "Patient Safety Action Teams" to support the delivery of the national patient safety agenda by local NHS organisations. The team should consist of experts with skills in data analysis, incident investigation and solution development. The patient safety managers (28) in England were transferred to SHAs to be core members of the SHA patient safety action teams as of 1 April 2009. the Agency now provides a national network of events and communications. It provides policy support for the SHA leads in patient safety.
7Prime responsibility for incident investigation should reside with local NHS organisations. Every NHS organisation should have access to a specialist investigator based within the Patient Safety Action Team. All reports should be considered locally within 24 hours of being reported. The NPSA should be notified of events that involve serious patient harm and death within 36 hours of the initial report. The NPSA has developed refined tools and techniques to help patient safety action teams support local organisations with their incident investigations.
8Accountability for patient safety rests with the Chair and Board of each NHS organisation. Each Board should therefore be expected to outline how it intends to discharge this responsibility. Importantly, each initiative should also make clear how it intents to ensure that patients and carers play an integral part in all initiatives to introduce a patient safety culture change within the NHS. The NPSA provides training at the induction for all non-executive Directors via the appointments commission induction process. The Agency is also working with the campaign team to help them deliver the key leadership intervention to make patient safety the highest priority for NHS organisations.
10A pilot should be established to examine the option of the National Institute for health and Clinical Excellence (NICE) developing technical patient safety solutions. The NPSA worked with NICE on 2 technical solutions.
11The NHS Institute for Innovation and Improvement should be asked to work with the medical Royal Colleges and other education providers to ensure that advances are made and training to support patient safety. The NPSA is working with the NHS Institute for Innovation and Improvement on training programmes for patient safety.
12All NHS organisations should develop and implement local initiatives to promote greater openness with patients and their families when things go wrong and provide required support. The NPSA has supported the review of Being Open by Prof A Wu and is holding a workshop at the end of September 2008 to bring together key stakeholders to take forward Prof Wu's recommendations.
13The active involvement of patients and their families should be promoted by establishing a national network of patient champions who will work in partnership with NHS organisations and other key players to improve patient safety; the network should also have strong links with WHO World Alliance for Patient Safety's "Patients for Patient Safety" initiative. A joint project has been established between NPSA and Action Against Medical Accidents (AvMA) to develop the role and responsibilities for patient safety champions. 22 Patient Safety Champions have been recruited. They have had a 2 day induction and a follow up development meeting. Their first year will be to focus on supporting the promotion of Being Open and Patient and Public Reporting.

Table 2  Progress related High Quality Care for All

DescriptionProgress to date
Never EventsThe NPSA has developed a list of 8 "never events". The aim is to include the Never Events in the NHS Operating Framework for 2009/10 in order to: Provide key indicators for patient safety ie if a never event occurs it is an indicator that the organisation has not yet put in place systems to prevent their occurrence, Enhance transparency and accountability when patient safety incidents occur, Provide further impetus to reducing serious, preventable and costly errors, Support commissioning leading to better, safer care, and Place patient safety at the core of the management of NHS organisations at all levels from the Board to the ward. The four key criteria for inclusion as a Never Event for 2009/10 are: The Never Event potentially may result in severe harm or death to patients. There is evidence that the Never Event has occurred in the past (data sources National Reporting and Learning System (NRLS) and Serious and Untoward Incident Reporting systems). There is existing national guidance and/or national safety recommendations that advise on how the Never Event can be prevented. Occurrence of the Never Event can be measured on an ongoing basis. The NPSA is working with primary care commissioners to develop the process to pilot on 2009. There will be clear definition of the Never Event to minimise the risk of perverse incentives and organisations will be reminded of the evidence and the guidance.
Matching Michigan The NPSA is working with Johns Hopkins Hospital in the US and will be designing an initiative to replicate the work in Michigan to reduce the number of central line infections in adult ICUs. Matching Michigan will be a collaborative approach to implement a number of interventions. The NPSA will commence the project in April 2009—driving change and monitoring success over a 9 month period.
Patient Safety DirectPatient Safety Direct is in the start up phase—scoping the issues and developing the business case. Its main objectives are in the short term, to improve reporting from clinical staff, in the medium term, to improve reporting of serious incidents and in the long term capture contributory and causal factors.

Annex 4


  A patient safety incident is any unintended or unexpected incident which could have or did lead to harm to one or more patients.

  Patient Safety Incident categories of harm are:

Level of harmDescription
No HarmImpact prevented—any patient safety incident that had the potential to cause harm but was prevented, resulting in no harm Impact not prevented—any patient safety incident that ran to completion but no harm occurred
Low Any patient safety incident that required extra observation or minor treatment
Moderate Any patient safety incident that result in a moderate increase in treatment and caused significant but not permanent harm
SevereAny patient safety incident that appears to have resulted in permanent harm
DeathAny patient safety incident that directly resulted in the death of a patient

Department of Health (2000). An organisation with a memory. Department of Health Back

214   NPSA/NHS Confederation Policy Briefing on High Reporting Trusts at Back

215   Percentage and numbers from the total incidents in England and Wales 1 April 2007 and 31 March 2008 Back

216   Levels of harm defined in Annex 4 Back

217   Reason, J. (2000). Human error: models and management. British Medical Journal 320, 768-770 Back

218   Leatherman, S. and Sutherland, K. (2008). The Quest for Quality: Refining the NHS Reforms, The Nuffield Trust. Back

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Prepared 30 October 2008