1. NPSA’s role in complaints

2. Failures in standards of care
DYSFUNCTIONAL POOR
SERVICE PRACTITIONER
PERFORMANCE
SYSTEM
WEAKNESSES SUBOPTIMAL
SERVICE
DELIVERY

3. Healthcare Responsibilities
Commission National Clinical
Assessment
Service
DYSFUNCTIONAL POOR
SERVICE PRACTITIONER
PERFORMANCE
PATTERNS &
SYSTEMS SUBOPTIMAL
SERVICE
DELIVERY
National Patient
Safety Agency
Trust Boards and Strategic Health Authorities

4. Purpose of the NPSA
Special health authority with mandate to:
– implement a national reporting system
for patient safety incidents
– collect and appraise information to
promote patient safety
– provide advice and guidance and monitor
its effectiveness
– promote research which contributes to
patient safety
– report and advise Ministers on matters
affecting patient safety

5. Understanding the context of
complaints

6. Vision for NPSA Creating a Safer NHS
Current Position Future Position
Blame the reporter Praise the reporter
Keep quiet Open and Learning Environment
Safety is an ‘Add on’ Integration into care processes, education,
R&D Programmes and Performance Assessment
Professional and National and International Partnerships
Organisational Silos Team Work,
Local Quality Networks
Patient and public involvement
Crisis Clear Management systems
Agreed work programmes for high impact,

7. Understanding the nature of error
and harm
Levels of error and harm

8. The National Reporting and Learning
System (NRLS)
• Confidential reporting database
• Incidents are reported electronically
• 99% come from Local Risk Management Systems
• Analysis of data at national level to
– identify trends and patterns
– provide feedback for local action
– inform NPSA work programmes

9. Care setting
Care setting No. %
Acute / general hospital 839,974 71.6
Mental health service 164,810 14.1
Community nursing, medical and therapy
service (incl. community hospital) 116,633 9.9
Learning disabilities service 37,663 3.2
General practice 4,916 0.4
Ambulance service 4,160 0.4
Community pharmacy 3,943 0.3
Community and general dental service 353 0.0
Community optometry / optician service 13 0.0
Total 1,172,465 100.0
Source: reports to the NRLS up to Dec 2006

10. Degree of harm to patients
Degree of harm No. %
No harm
798,221 68.0
Low
295,562 25.2
Moderate
64,647 5.5
Severe
10,827 0.9
Death
4,588 0.4
Total
1,173,845 100.0
Source: reports to the NRLS up to Dec 2006

11. Seeing the whole picture

12. NPSA must use all available data
sources to inform safety
• Administrative data
• Clinical incident reports
• Medical records
• Active surveillance or observation
• Surveys - patients, staff
• Complaints data

13. Other datasets. Patient Safety OTHER
• Clinical negligence Research ORGANISATIONS
• MHRA
• Hospital Episodes
• GP Databases
•complaints
Other confidential PRIORITISATION
reporting systems
Surveillance &
Monitoring SOLUTIONS
NRLS
OBSERVATORY EVALUATION
Intelligence NHS Feedback
- Healthcare Commission
- Expert Groups
- Patient/Public
- DH/Ministers
- Interest Groups etc.
R&D
Research Public/Patient PATIENTS/
eForm
PUBLIC

14. Learning from the NRLS and the
PSO

15. Routine and thematic reports
• Thematic reports
• Bulletin
• Trust feedback reports

16. Patient Safety
Observatory reports

17. Patient Safety Bulletin

18. Routine infusion of fluids
• Single report of fatal incident
following inappropriately
prescribed fluids
• Few reports related to this –
not a well recognised risk?
• Recommendations

19. Comparative feedback reports

20. Ad hoc analysis
• Requests from NHS clinicians and risk managers, and relating
to current NPSA projects
• Use of categorical data supplemented by text searching tool
• Examples during one week:
– Chest x-ray for work on failure to review x-ray results
– Clinical oncology/bone marrow
– Learning disabilities choking incidents
– Surgical incidents relating to policies and protocols
– Maternity beds (elliot and lic types)
– Non-medication prescriptions
– Home oxygen therapy
– Collapsible curtain rails

21. Systematic review of incidents
• Richness of NRLS data in free text
descriptions review from clinical perspective
adds value
• Huge volumes of data – sampling by specialty
and incident type
• Tools to support robust and consistent review
of data supported by guidance and decision
tree for follow-up action

22. Number of incidents
W
W ro
0
50
100
150
200
250
300
350
ro ng
W ng si
ro op de
ng er
pa at
tie io
n
W nt
ro C de
In ng ha
ng ta
co or ils
m m
es
pl is to
et si
e ng list
op pa
er tie
at
N io
n
nt
o
si de
de ta
S ils
pe id
ci en
al tif
in ie
st d
In ru Inc
ap ct o
io rre
c
Operating list incidents
pr ns
op m t
ria is
te si
ng
al
lo
ca
tio
n
O
th
er
to end Oct 06
Source: NRLS,

23. Under-reporting (and bias)
• From case note review studies, estimated
that LRMS capture 11-17% of patient safety
incidents
• Does under-reporting matter?
• Alternative reporting routes - bias

24. Access, admission, transfer Incidents from multiple
Clinical assessment sources in a one hospital
Consent, communication, confid
• Incidents
Disruptive aggressive behaviour • Complaints
Documentation • Claims
Implement of care, ongoing • Inquests
monitoring and review
Infection control incident
• LIRS
Infrastructure
• Casenotes
• PAS
Medical Device
• Datix HS
Medication
• MHRA
Patient abuse
• Audit
Patient accident
• Micro Surv
Self harming behaviour
Treatment, procedure Source: Hogan et al

25. Conclusion
• Complaints data is one useful source of data to be
used for safety improvement but because people
respond to complaints in a variety of ways including
being defensive and or not fully disclosing information
other multiple sources are needed.
• This provides a better more holistic picture of patient
safety than any one data set could do so.

26. “Kevin died. Kevin should not have died. We mourn
for Kevin. ….. The tragic outcome in relation to
Kevin cannot be changed. But can that outcome be
a catalyst for change in the reformed health service?

27. By examining Kevin’s patient journey there
can be real learning and real improvement at
all points of patient contact. Perhaps Kevin’s
destiny was to highlight for us the deficiencies
and the challenge for us is to learn from his
experience and to ensure that healthcare is
safer for future patients.”
(A patient’s mother)