The Context Some facts and figures The interventions - The World Alliance for Patient Safety The...

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The Context • Some facts and figures • The interventions - • The World Alliance for Patient Safety • The Patients for Patient Safety initiative

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Page 1: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

The Context

• Some facts and figures• The interventions - • The World Alliance for Patient Safety• The Patients for Patient Safety initiative

Page 2: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

Severity of incidents by care setting, April 2006 to March 2007

Some facts and figures

Page 3: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

Number of patient safety incidents reported, by quarter, 10/2003 to 9/2007

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Reported incidents by type, July 2006 to June 2007

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Care setting of incident reportsJuly 2006 to June 2007

Page 6: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

Reported degree of harm to patients, July 2006 to June 2007

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The intervention - Working in Partnership with Patients

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Patients For Patient Safety

Part of the WHO Alliance for Patient Safety

Page 9: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

Who are we?• Susan Sheridan*

• Co-founder Consumers Advancing Patient Safety, USA (Chair) • Peter Mansell*

• Director for Patient Experience and Public Involvement, National Patient Safety Agency, England and Wales

• Martin J. Hatlie• President, Partnership for Patient Safety, USA

• Garance Upham*• People's Health Movement, Disability and Economics Circle

• Jo Harkness• Policy & External Affairs Director. International Alliance of Patients'

Organizations • Helen Hughes

• World Health Organisation (Secretariat)

* = people who have experienced harm

Page 10: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

The aimTo generate:• a patient centred approach in patient

safety in health• consumer interest and networks in patient

safety in/with • the Alliance’s work strands• each other

• and apply a method of identifying patient safety champions

Page 11: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

The Group’s role• Defined in the statement of case

1. to help clinicians get the • whole picture (we are often the only people who

see this) • and understand issues from a patient’s

perspectives such as social and economic aspects

2. PFPS participating as equals; not victims.3. We expect the spirit to be willing from

professionals but default behaviours to mean we have to speak up!

Page 12: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

Current work

• About 200 activists from around the world working• Consumer champions’ workshops in WHO regions and

within countries• WHO regional offices developing patient safety strategies • Solutions products• Research

• developing tools to measure harm• working with teams delivering studies

• The global patient safety challenge• pilot sites• guidelines content

Page 13: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

The patient involvement landscape and experience within England

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Reference points• When things go wrong, [patients] and their families

suffer from the harm caused. Such harm is often made worse by the defensive and secretive way that many healthcare organisations respond in the aftermath of a serious event.

• Partnership must be a key theme: patients, health professionals, policymakers and healthcare leaders should be working together to prevent avoidable harm in healthcare. A particular focus is to challenge the current culture of denial.

(Safety First 2006)

Page 15: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

Where can patients add value?

• Sharing their insights• Offering different perspectives• Using experience for improvement

Page 16: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

Sharing insights - AnticoagulantsProcess steps Patient experience and barriers to safe use

Decision to treat Use of medical jargon and abbreviations unhelpful. Lay knowledge of warfarin is as “rat killer” and this use needs to be described in context of patient anticoagulation for some.

Document andCommunicatediagnosis andtreatment plan

Poor communication with carers. Stroke patients receive less information and support than others. No planning for coping during first four weeks post-discharge, nor for longer term regarding schooling, holidays, and other social events. Lack of information about effect of foods and alcohol on anticoagulation control. Overall discharge is the weakest yet critical stage.

Prescribe Lack of communication between hospital consultant / clinic and GP when new drugs are introduced – other prescribers can be unaware of this. Conflicting information about aspirin; some are prescribed whilst others are told to avoid – the reasons for this need to be explained. Conflicting advice is a source of anxiety – patients do talk to one another and compare treatments.

Monitortreatment

Home testing appreciated by patients but not by clinicians.

Page 17: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

Offering different perspectives - number of trusts that regularly report to the NRLS

• October 2003 to December 2007 - 2,145,606 PSIs• Of the 427 NHS organisations in England and Wales,* 89%

reported at least once between October to December 2007

• 57% of all NHS organisations didn’t report at least once per month

Page 18: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

Using experience for improvement - views on medication – implications for commissioning

• Design• Two people reported mistakes made in the use of

insulin pens, (slow-release and a quick-release), which look identical. When one person was about to go hypoglycaemic, they picked up the slow-release pen by mistake and ended up in hospital. “This is easy to do when you’re in a hurry and anxious”.

Page 19: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

Language, names and look of drugs

• Several participants described how a change in the brand of a prescribed drug can create serious problems, causing confusion and increasing the risk of mistakes being made

• Implications for the NHS in commissioning: • Spot market purchase brings its own set of risks

when viewed by patients• Different look/Language/Names

Page 20: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

So the impact of involving patients can be to• Provide new knowledge• New ways of seeing things .. and so ..• Provide a way to reconnect with people who

have lost trust

Page 21: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

The NPSA contribution to you – making space for staff and patients*• May workshop linked to the Patient Safety Congress

• To foster and build collaboration and links between patients and staff on the range of patient safety efforts at regional and local levels, so that lessons can be shared and partnerships created.

• Three summit events aimed at answering:• What do safe health services look like?• What do safe GP services look like?• What do safe Mental health services look like?

• Autumn workshop aimed at SHA alliances/federations and patients to review work to date

Page 22: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

Formational Workshops

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Closing message

• Patient safety • Can’t be achieved without the active

involvement of patients and those close to them

• Is about trust and transparency as well as reducing error and harm

• Our role is to help staff and patients regionally and locally work together

Page 24: The Context Some facts and figures The interventions - The World Alliance for Patient Safety The Patients for Patient Safety initiative.

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