Patient Safety Publications and Websites

Below is a list of patient safety resources, both publications and websites. For each resource you will find a brief summary of what it contains. We hope you will find this helpful for TAPS and in future patient safety initiatives.

An organisation with a memory. Department of Health. 2000  www.dh.gov.uk/

  • This document was written for the Department of Health by the Chief Medical Officer (amongst others) in 2000 outlining the current systems in place for learning from errors in the NHS and a plan for a reform of the system.
  • This document introduces many of the key themes and ideas regarding patient safety and many case studies from both the NHS and other industries
  • It was the seminal paper in the focus on patient safety of the new millennium.

Themes:

  • Many failures in care could be avoided if the lessons of experience were properly learned
  • Official figures per year showed (mainly derived from a few effective reporting services such as confidential enquires and yellow card adverse drug reporting or from research):
    • 400 deaths or serious injuries as a result of medical devices
    • 10,000 serious adverse reactions to drugs
    • 1150 commit suicide after having been in recent contact with mental health services
    • 28,000 written complaints
    • £400 million in settlement of clinical negligence claims
    • £1 billion spent as a result of healthcare associated infection
    • It is estimated that harm was caused to patients in approximately 10% of admissions, costing £2 billion/year
  • Some specific adverse events (such wrong drug intrathecal injections) were repeated consistently and lessons were not being learnt
  • The UK had a lack of research (when compared with countries such as the USA) into preventing harm to patients
  • The blame culture is no longer an acceptable method of dealing with adverse events as it is usually systems error, not clinical negligence which causes harm
  • Work needed to be done on both organizational change and reporting systems (which had no standardized format, near missed were seldom documented and were particularly poorly developed in primary care)
  • There was no single focal point for NHS information regarding adverse events and as a results recommendation implementation was patchy and lessons learned rarely shared
  • The report concluded that the NHS needed a unifying reporting system, an open culture of incident and near miss reporting, a mechanism of change following lessons learned and a systematic approach to preventing, analyzing and learning from error.

WHO Alliance for patient safety

Patients for patient safety  www.who.int

  • Launched in 2004, highlights the central role that patients can play to improve safety and quality in healthcare around the world
  • Supports patient involvement in patient safety programs
  • Aims to improve healthcare safety in all healthcare settings
  • Main work is the provision of workshops, drawing patients and patient safety advocates from around the world to share experience, knowledge and hopes, watch informal presentations and meet with key opinion leaders in patient safety and patient safety champions
  • By involving the patient, a healthcare organization is able to provide a truly patient-centred solution to patient safety issues.

Clean care is safer care  www.who.int

  • The first global patient safety initiative
  • Aim is to ensure that hand hygiene stays on the national and international health agenda and to ensure that infection control is acknowledged universally hence reducing healthcare associated infections
  • Has support of 121 member states
  • Encourages healthcare institutions to adopt the WHO’s ‘5 moments for hand hygiene’
  • As part of this, the SAVE LIVES: clean your hands campaign was launched on 5 May 2009 aimed at increasing hand hygiene compliance

WHO Surgical checklist  http://www.who.int/

  • Aims to improve peri and intra-operative surgical safety as part of the Safe Surgery Saves Lives Challenge by ensuring adherence to proven standards of care.
  • There are 3 phases to the checklist:
  • SIGN IN (before induction of anaesthesia): Checking patient identity, consent, procedure, site (and ensure marked), anaesthesia safety check, allergy status, risk of aspiration/difficult intubation, risk of > 500ml blood loss
  • TIME OUT (before first skin incision): Introduction of team members by name and role, Surgeon/anaesthestist/nurse all verbally confirm patient name, site and procedure, anticipated critical events, antibiotic prophylaxis, imaging required and displayed if needed
  • SIGN OUT (before patient leaves theatre): Confirm the name of the procedure, instrument, sponge and needle counts correct, labeling of any specimens, any equipment problems, post-operative concerns/instructions for the patient verified.
  • Data from a multi-centre trial published in the NEJM trialing the checklist showed a reduction in rate of major complications and surgery related deaths of one third

WHO Patient Safety Curriculum Guide for Medical Schools  www.who.int

  • A new scheme recently drafted by the WHO to encourage and facilitate the teaching of patient safety topics to medical students
  • A draft version of the Curriculum is available via the WHO website and results of pilot studies are awaited
  • Even though this is designed for medical students, it is well worth a look for a comprehensive guide on ‘patient safety’. Once finished it should be a fantastic resource for delivery of patient safety education to medical students and junior doctors.

NHS constitution  http://www.dh.gov.uk/

  • A document published in January 2009 outlining what staff, patients and the public can expect from the NHS. Its introduction and some passages pertaining to the patient safety agenda are outlined below.
  • The NHS belongs to the people. It is there to improve our health and well-being, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives. It works at the limits of science – bringing the highest levels of human knowledge and skill to save lives and improve health. It touches our lives at times of basic human need, when care and compassion are what matter most.
  • You have the right to expect NHS organisations to monitor, and make efforts to improve, the quality of healthcare they commission or provide.
  • The NHS also commits: to ensure that services are provided in a clean and safe environment that is fit for purpose, based on national best practice....when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively; and to ensure that the organisation learns lessons from complaints and claims and uses these to improve NHS services.

Patient safety first campaign  http://www.patientsafetyfirst.nhs.uk/

  • Run by the National Patient Safety Agency (NPSA) with the aim of changing the culture within the NHS to ensure that it makes patient safety its first priority and makes all avoidable death and harm unacceptable
  • Provides NHS staff with the knowledge and support they need to improve safety
  • Has 5 key interventions:

Leadership for safety: Aims to ensure leadership at board levels promotes quality and patient safety and provides environment for continuous improvement in harm reduction
Reducing harm from deterioration: Aim to reduce the rate of cardiac arrest and death by the earlier recognition of the deteriorating patient. Promotes the use of regular observation to trigger warning signs for the deteriorating patient (such as MEWS scores) with escalation protocols and effective communication strategies.
Reducing harm in critical care: aims to improve the care of patients in the critical care environment via two care bundles based around interventions named ‘the ventilator bundle’ (head elevation, daily assessment of readiness to extubate, PUD prophylaxis, DVT prophylaxis) and ‘the central line bundle’ (hand hygiene, barrier precautions, chlorhexidine skin antisepsis, optimal catheter site selection, daily review of central line necessity).
Reducing harm in peri-operative care: Aims to improve care for patients undergoing elective surgery via two elements: Reducing surgical site infections (appropriate antibiotic use, use of recommended hair removal methods, adequate glycaemic control in diabetics, maintenance of post-operative normothermia) and Improving teamwork and communication via the WHO Surgical Safety Checklist.
Reducing harm from high-risk medicines: Designing processes to prevent errors and harm, methods to identify error and mitigate the harm that may result from the error when prescribing/administering high risk medications (anticoagulants, opiates, injectable sedatives, insulin).
 

Root cause analysis toolkit  http://www.npsa.nhs.uk/

  • An e-learning module developed by the NPSA which explains the rationale behind root cause analysis and how to perform and effective investigation based on this technique.

The Institute for Healthcare improvement  http://www.ihi.org/

  • The website for the Institute of Healthcare Improvement, a non-profit making independent organisation aimed at helping to lead healthcare improvement internationally. 
  • Documents available free of charge on many dimensions of healthcare improvement and patient safety.
  • e-learning modules on patient safety topics which are aimed at healthcare professionals
  • Details on the recent ‘5 million lives campaign’ which was a project carried out in the USA to reduce harm to patients.

Further reading on patient safety

Prof James Reason
Reason, J. Human error. Cambridge, MA: Cambridge University Press, 1990. Google Books overview

Reason, J. Managing the risks of organizational accidents. Aldershot: Ashgate, 1997. Google Books overview:

Prof Don Berwick
Berwick, DM. Continuous improvement as an ideal in health care. New England Journal of Medicine. 1989; 320(1):53-56. Abstract

Berwick, DM, Calkins, DR, McCannon, CJ, Hackbarth, AD. The 100 000 Lives Campaign: Setting a goal and a deadline for improving health care quality. Journal of the American Medical Association. 2006; 295:324-327. Abstract 

Dr Lucian Leape
Brennan, TA, Leape, LL., Laird, NM, et al. Incidence of adverse events and negligence in hospitalized patients: Results from the Harvard Medical Practice Study I. New England Journal of Medicine. 1991; 324:370-376. Abstract

Leape, LL, Brennan, TA, Laird, NM, et al. The nature of adverse events in hospitalized patients: Results from the Harvard Medical Practice Study II. New England Journal of Medicine. 1991; 324:377-384. Abstract

Leape, LL, Error in Medicine. Journal of the American Medical Association. 1994; 272:1851-1857. Abstract

Kohn LT, Corrigan JM, Donaldson MS. Institute of Medicine, Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Washington, D.C: National Academy Press, 1999. Full text

Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy of Sciences, 2001. Full text

Prof Charles Vincent
Vincent, C, Neale, G, Woloshynowych, M. Adverse events in British hospitals: preliminary retrospective record review. British Medical Journal. 2001; 322:517-519 Full text
 

Vincent, C. Patient Safety. Philadelphia, PA: Elsevier, 2006. Google Books overview 

Prof David Bates
Bates, DW, Leape, L, Cullen, D, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Journal of the American Medical Association. 1998; 280:1311-1316. Full text
 

Bates, D, & Gawande, A. Improving safety with Information Technology. New England Journal of Medicine. 348 (25): 2526-2534, 2003. Full text

John Sandars and Gary Cook
Sandars, J & Cook, G. ABC of patient safety. Oxford; Blackwell; BMJ Books, 2007. Google Books overview


Websites of patient safety agencies from around the world

UK               http://www.npsa.nhs.uk/
USA             http://www.patientsafety.gov/
Canada      http://www.patientsafetyinstitute.ca/
Australia     http://www.apsf.net.au/
Denmark    http://www.patientsikkerhed.dk/
 

Acknowledgements:
Thanks go to Laura Dobson ( and BAMMbino) for producing this list of resources.