Select Committee on Health Written Evidence


Memorandum by the Royal College of Nursing (PS 44)

PATIENT SAFETY

1.0  EXECUTIVE SUMMARY

  1.1  Clinical practice can never be risk-free, human error and poor judgement will always contribute to patient safety risks.

  1.2  However risk is not simply created by individuals. It is most important to acknowledge the role of the context in which care is delivered and the impact this has on individuals' performance and capacity to deliver safe care.

  1.3  Focus on specific issues such as key Healthcare Associated Infections (HCAIs) has been beneficial in bringing about some change and improvement. However there is some concern that publicity surrounding hospital acquired infections may distract from other important patient safety issues.

  1.4  A particular concern for patient safety is when there are "broken processes" in the health care system, for example: failure to communicate appointments; loss of records; patients with co-morbidity being treated by different parts of the service acting in isolation; inequality of access to specialist services; and failure to manage and provide appropriately skilled staff.

  1.5  Technology must meet the highest requirements for usability in the care setting, and staff and patients require appropriate skills to use it safely and effectively.

  1.6  Not enough is known about the impact of poor "health literacy" and its implications for patient safety.

  1.7  Clearly the main driver for better patient safety in all settings will be the new Care Quality Commission. The RCN has consistently made the point that regulation of health and social care needs to be adequately funded.

  1.8  Patient safety initiatives must be linked with the Human Resources Framework. We believe that a failure to implement effective HR systems can impact on patient safety.

  1.9  There is a professional responsibility to report incidents and near misses, and nurses are among the best professional groups in terms of reporting patient safety incidents. The blame culture still exists in some environments and this may contribute to under reporting of staff or patient related incidents.

  1.9.1  The RCN feels that education and training of staff is an important component in contributing to the management of risk. There is a real need to support staff to increase their understanding of patient safety and devise ways of maintaining their knowledge and skills over the course of their working lives.

  1.9.2  Support is also needed for senior nurses to influence governance structures.

More work needs to be done in assisting senior staff within organisations to gather data to inform their understanding of where best to target action and improvement.

  1.9.3  The RCN also feels that there is an increasing need to focus on work-based learning approaches when addressing patient safety.

  1.10  There is still work to be done exploring the ways in which patients and the public can be involved in ensuring that services are safe. Patient experience can provide a key focus for this.

2.0  INTRODUCTION

  2.1  With a membership of over 390,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations. The RCN welcomes the opportunity to contribute to the Health Select Committee Inquiry into Patient Safety.

3.0  QUESTION 1:  WHAT THE RISKS TO PATIENT SAFETY ARE AND TO WHAT EXTENT THEY ARE AVOIDABLE, INCLUDING:

    —  Role of human error and poor clinical judgement

    —  Systems failures

    —  How far clinical practise can be risk free; the definition of "avoidable" risk; whether the "precautionary principle" can be applied to healthcare.

    —  The role of public perceptions of risk in determining NHS policy

  3.1  Clinical practice can never be risk-free, human error and poor judgement will always contribute to patient safety risks. The issue is therefore how best to reduce risks to the lowest possible level. A blame free culture should encourage learning from near misses and human error. Problems surrounding negligence and incompetence will also need to be considered, dealt with by the appropriate regulatory bodies and also any learning captured from these events to inform adjustments where relevant to professional development and support systems.[256]

  3.2  However risk is not simply created by individuals. It is most important to acknowledge the role of the context in which care is delivered and the impact this has on individual's performance and capacity to deliver safe care. This raises notions not only of organisational awareness of risks but also of their active response to these. For example, the recent investigations into patient deaths as a result of failures in infection control at Tunbridge Wells and Stoke Mandeville told us what we already knew, that latent failures as a result of poor design, poor management practices and focusing on the financial bottom line adversely affect patient safety. The role of necessary and appropriate sanctions still needs to be clarified. In the examples above, no sanctions appear to have been applied to either hospital and it is unlikely that any charges of corporate manslaughter will be levelled against the senior management of these and future failing organisations.

  3.3  Additionally, there is an increasing debate on the role of visitors and Healthcare Associated Infections (HCAIs). The impact of this has, in some cases resulted in an increasing emphasis being placed on visitor hand hygiene rather than staff hand hygiene as a focus for reducing HCAIs. Healthcare organisations need to retain a clear focus of where the risks exist in the patient care pathway. Focus on specific issues such as key HCAI has been beneficial in bringing about some change and improvement. However, there is some concern that publicity surrounding hospital acquired infections may distract from other important patient safety issues (Anger over hospital clot deaths http://news.bbc.co.uk/1/hi/health/6668375.stm). Robust data is needed to assist in targeting future interventions and ensuring that focus in one area does not preclude attention to others which need to be of equal concern. There is a significant move to developing a zero tolerance approach to healthcare associated infections with a "target" of zero infections set as a mandatory requirement (MRSA bacteraemia and C. difficile). In practice however, there is a need for clarification and a more objective review of what is achievable as there is a risk of unintentionally influencing healthcare worker, public and media opinion on this issue. A more realistic view could determine the value of zero "avoidable" infections which acknowledges the complex and multi-factorial issues affecting the development of infections; however case definitions for what constitutes an "avoidable infection" would be required.

  3.4  A particular concern for patient safety is when there are "broken processes" in the health care system, for example: failure to communicate appointments; loss of records; patients with co-morbidity being treated by different parts of the service acting in isolation; inequality of access to specialist services; and failure to manage and provide appropriately skilled staff. National Health Services in the UK are committed to developing the Electronic Patient Record (EPR). The EPR linked to better quality management system has potential to address all these issues by: linking management of individual care to pathways with appropriate referrals; supporting a co-ordinated approach to co-morbidity (particularly in management of long term conditions); and improving information to help balance service requirements with the provision of suitably skilled staff.

  3.5  Technology must meet the highest requirements for usability in the care setting, and staff and patients require appropriate skills to use it safely and effectively. The increasing use of "User Experience" expertise by NHS England's Connecting for Health programme is welcome evidence of this, as well as their engagement with professional bodies in assuring the quality of projects like the "Common User Interface".[257]

  3.6  There is a knowledge gap in our understanding of safety issues in primary and community care settings. The Commonwealth Fund's International Health Policy Survey (2005) indicated that 75% of medical errors/medication mistakes occur outside of hospital.

  3.7  Not enough is known about the impact of poor "health literacy" and its implications for patient safety. Neither is enough known about the potential for ICT to mitigate or indeed increase risk but there is the potential for it to be a considerable force for improving patient safety. Nurses are often the critical point of contact with patients in the delivery of care. Nursing therefore needs to have a strong presence in ICT developments in order to ensure nursing perspectives are effectively captured.

4.0  QUESTION 2:  WHAT THE CURRENT EFFECTIVENESS IS OF THE FOLLOWING IN ENSURING SAFETY:

    a.  local and regional NHS bodies, and other organisations providing NHS services (including primary and community care, and mental health services)

    —  How far the boards of NHS bodies have established a safety culture

    b.  systems for incident reporting, risk management and safety improvement

    —  Whether adequate measurement and assessment is undertaken and acted upon.

    —  The impact of the changing public-private mix in provision

    c.  national policy

    —  The appropriateness of the objectives set out in national policy statements, including Safety First and High Quality Care for All, and what progress has been made in meeting them

    —  Whether past spending on patient safety has been sufficient and cost effective, and what future spending should be

    —  The appropriateness of national targets

    d.  the National Patient Safety Agency and other bodies, including:

    —  Healthcare Commission / Care Quality Commission

    —  NHS Litigation Authority

    e.  education for health professionals

  4.1  Looking at the terms of reference we question why they are so focused on the NHS and Health when we are in an environment of increasing plurality of providers and the general direction is towards the integration of health and social care? It may be useful to be asking more questions about what more can be done to ensure patient safety across all settings. ie, when saying "determine best practice and ensure it is spread throughout the whole NHS, why isn't the question being asked about how to `ensure it is spread throughout the whole health and social care economy"?

  4.2  Clearly the main driver for better patient safety in all settings will be the new Care Quality Commission. The RCN has consistently made the point that regulation of health and social care needs to be adequately funded. The new Commission will start its life with a much reduced budget which some believe will be insufficient to enable the Commission to really fulfil its new responsibilities and drive up quality. The aims of the new Commission have been set out in its first manifesto which the RCN has welcomed. The government needs to support the new Commission by increasing its budget.

  4.3  The Healthcare Commission (Learning from Investigations 2008) identified weak leadership, ineffective management and poor use of systematic information as key reasons why patient safety is put seriously at risk. NHS Trust boards fail on patient safety because it is unclear who is responsible for maintaining safety and staff feel unable to speak out when problems occur. The RCN's experience in campaigns such as the "Nutrition Now" and "Wipe it Out" is that Directors of Nursing are challenged to get quality and safety issues on the agendas of Trust Boards.

  4.4  Where high level patient safety initiatives eg deep cleaning are undertaken, there needs to be clear evaluation of their impact. Staff can become cynical about the value of future projects when they are unclear about the overall impact of past or current ones. The DH spends 100 times more on research than on clinical audit. A better allocation of resources to learn from quality improvement initiatives is needed.

  4.5  Similarly we wonder what the impact of the diversion of funds from agencies (CGST, NHS Institute for Innovation and Improvement) to SHAs in England will be on workforce learning about these issues. What is the capacity of SHAs to deliver requisite training on these issues?

  4.6  Patient safety initiatives must be linked with the Human Resources Framework. We believe that a failure to implement effective HR systems can impact on patient safety. The RCN contributed to a workshop recently to look at how HR systems can be used to work towards lower rates of infection control. The principles outlined in the document could equally be applied to improvements in patient safety through mechanisms such as the NHS Knowledge and Skills Framework and appraisals. Employers need to fully implement HR frameworks and understand the link with patient safety. There is a need to strengthen training/education around incident reporting as staff continue to report risks differently in terms of probability and severity. This is currently dependent on individual interpretation by the person who reports the risk and managers who counter sign the report. Variation in reporting will lead to discrepancies in data production and potential learning as a result. Greater emphasis on patient safety and incident reporting is required and should be considered as part of the annual mandatory training update for all NHS Trusts/healthcare providers. Strengthening the link between HCAI's and patient safety through education/training would serve to enhance the understanding and compliance by staff through the establishment of an integrated safety culture.

  4.7  There is a professional responsibility to report incidents and near misses and nurses are among the best professional groups in terms of reporting patient safety incidents. However, we have evidence of under reporting in relation to staff related incidents (specifically violence and needlestick injuries), and the use of data to inform local practise. Learning from incidents also varies considerably across organisations.

  4.8  The blame culture still exists in some environments and this may contribute to under reporting of staff or patient related incidents. A National Audit Office report (2005) showed that under reporting is a real issue (50% of respondents indicating 20% of incidents go unreported; 75% indicated that 20% of near misses go unreported, while 22% put the figure as high as 39%). The reasons for this need to explored eg does this reflect a lack of staff faith in an organisation's ability to act on feedback? Fear of blame culture? Either way this would seem to indicate an area of concern. Anecdotal evidence leads us to understand that it is not uncommon for a trust to discipline staff following incidents rather than go through NPSA root cause analysis processes. The lack of intelligence from primary care and community settings also hampers our understanding of events in these contexts. We are frequently told that reporting systems eg DATIX are complex and take too much time to complete, particularly for community based healthcare workers.

  4.9  The results of the RCN 2007 survey of Nurses' Employment and Morale entitled "Holding On" found that only a quarter of NHS nurses consider that there are sufficient staff to provide a good standard of care, and feel too busy to provide the care that they would like. Nurses working in wards with higher patient to nurse ratios are more likely to feel unable to provide the care they would like and are less likely to regard the standard of care provided as good. Although this is not an explicit association between "care" and "safety", the link is implied.

  4.9.1 The RCN feels that education and training of staff is an important component in contributing to the management of risk. This refers not only to registered staff but others who work at the "sharp end of care" such as Healthcare Support Workers. Employers need to be encouraged to view education and training as a necessary element in their actions to reduce risk and to support staff accordingly.[258]

  4.9.2  The 2005 RCN "At Breaking Point" survey of the wellbeing and working lives of nurses found that nurses score more poorly than the Health and Safety Executive average, showing that they are exposed to higher levels of stressors in their jobs. Official figures show that health service workers are more likely to be subject to work related stress than other professions. The Health and Safety Executive has highlighted that work related stress, particularly in safety critical environments can lead to an increase in errors, accidents and injuries. Whilst stress cannot be eradicated from the health service, employers need to do more to address the wellbeing of their employees by implementing the Health and Safety Stress Management Standards and to make an association between staff wellbeing and patient outcomes[259].

  4.9.3  Recent findings from the Healthcare Commission presented by Dr Veena Raliegh at a conference on 15th July (see http://www.nhsemployers.org/aboutus/aboutus-3877.cfm), linked the findings of the annual staff survey with patient experience survey and concluded that workforce issues are central to safe, high quality services. Specific associations relate to the availability of managerial support, awareness of procedures for reporting errors, frequency of reporting errors (ie willingness to report near misses etc.) and access to health and safety training.

5.0  QUESTION 3.  WHAT THE NHS SHOULD DO REGARDING PATIENT SAFETY

    —  Whether the measures taken to improve patient safety are supported by adequate evidence regarding their clinical effectiveness and cost effectiveness

    —  How to determine best practise and ensure it is spread throughout the whole NHS

    —  How to ensure that learning is implemented

    —  What should be measured and assessed; and what data should be published

    —  What incentives there should be to improve patient safety

    —  How patients and the public can be involved in ensuring that services are safe

  5.1  There is a real need to support staff to increase their understanding of patient safety and devise ways of maintaining their knowledge and skills over the course of their working lives. The RCN has a developing programme of support which encompasses production of public resources, online learning resources, and the development of activists/facilitators to support work based learning.

  5.2  Support is also needed for senior nurses to influence governance structures.

More work needs to be done in assisting senior staff within organisations to gather data to inform their understanding of where best to target action and improvement. The RCN feels that reinvigorated clinical audit will assist in this respect. The RCN is one of three organisations which collectively form the Healthcare Quality Improvement Partnership. We are also keen to promote the development and use of tools and resources which help staff review aspects of their organisation. To this end we have developed a Safety Climate Assessment Tool which we are beginning to use in collaboration with a small number of Trusts as part of their service improvement activities.

  5.3  We have also developed the capacity for large scale data capture projects in order to support nurses in the development of relevant audit, benchmarking and other data capture projects. We see these as a means by which NHS organisations can begin to address some of the challenges around patient safety—especially in terms of establishing and maintaining an effective safety culture. Further research is required to establish the link between clinical and cost effectiveness.

  5.4  At a macro level, there is some evidence of movement toward the "systematic sharing of experiences in national quality and safety strategies between countries"[260] which is to be encouraged. Work has commenced across the EU (EUNetPas) and the RCN is involved in this through its membership of the European Federation of Nurses Associations.

  5.5  It will be interesting to see how the introduction of the "Quality Accounts" proposed in Lord Darzi's report impacts on some of the issues of concern eg implementation and board involvement. We are firmly of the opinion that implementing any recommendations from evidence requires a positive culture in the workplace, linked to leadership and evaluation in practice.

  5.6  The RCN also feels that there is an increasing need to focus on work-based learning approaches. These provide benefit for the practitioners as well as the organisation and the factors that need to be in place to achieve this, such as an effective workplace culture.

  5.7  There is still work to be done exploring the ways in which patients and the public can be involved in ensuring that services are safe. Patient experience can provide a key focus for review, discussion, challenge and learning and the use of patient's stories for this purpose can be extremely effective. Patient representatives should be invited to attend Infection Control committees as standard. The RCN is developing a series of digital patient (and staff) stories which encompass safety issues and can be used by educators, staff groups and others as a part of quality and safety improvement activities.

September 2008








256   The precautionary principle can be applied to healthcare and indeed has been adopted by the American Nurses Association (http://www.nursingworld.org/DocumentVault/AJN/2004/AJNArticle.aspx). There is almost thirty years of safety research that has been undertaken in other safety critical industries. We need to be better at using that and not keep making the claim that healthcare is "different" to these other industries, as in many ways the challenges are similar. Back

257   A more detailed picture of risks is emerging, especially those that are associated with nursing in acute settings: Statistics Canada: Correlates of Medication Error in Hospitals. Report describing results of a large survey of Canadian nurses and identifying work-related factors that contribute to medication errors. (May 08). http://www.statcan.ca/english/freepub/82-003-XIE/2008002/article/10565-en.pdf "medication error was positively associated with usually working overtime, role overload, perceived staffing or resource inadequacy, low co-worker support, and low job security". Back

258   The results of the RCN 2007 survey of Nurses' Employment and Moral "Holding On" http://www.rcn.org.uk/_data/assets/pdf_file/0004/78763/003181.pdf found levels of mandatory training in the NHS low, particularly in relation to infection control, health and safety and use of equipment, where more than 30% of respondents reported receiving no training in the last 12 months. This also links in with the recent research by the HCC on staff and patient experiences (see last point). Back

259   Two sources linking staff welfare/HR framework with patient safety include: Lunstrom T, Pugliese G, Bartley J, Cox J, Guither C. Organizational and environmental factors that affect worker health and safety and patient outcomes. American Journal of Infection Control 2002; 30:93-106. Yassi A, Hancock T. Patient Safety- Worker Safety: Building a Culture of Safety to Improve Healthcare Workers and Patient Well-Being. Healthcare Quarterly Vol. 8, Special Issue October 2005 Back

260   World Health Organisation Europe (WHO): http://www.euro.who.int/Document/E91317.pdf Back


 
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