Paul Helliwell Clinical Specialty Advisor Dentistry Association of Dental Anaesthetists Winter Meeti

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Paul HelliwellClinical Specialty
AdvisorDentistryAssociation of Dental
AnaesthetistsWinter Meeting5th February 2005
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Content

• Background
• What we are
• What we are not
• Why patient safety is important
• What we do
• What you can do

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Content

• Background
• What we are
• What we are not
• Why patient safety is important
• What we do
• What you can do

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Why do doctors not report errors?

• If harm to a patient, shame and guilt
• Fear of litigation on admitting liability
• Fear of disciplinary measures/GMC/NCAA
• Not considered important if clinically trivial
  (no harm no problem)
• Lack of reporting discipline (unlike nurses)
• Failure to recognise system pathogens

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• Telling people to be more careful doesnt work
• We need easier, more intuitive systems to
  operate within

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How would you operate these doors?
Push or pull? left side or right?
A
B
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How would you operate these doors?
How did you know?
A
B
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Changing the culture

• Person centred approach
• error prone people
• Find someone to blame punish, shame and train
• fix individual improve safety

• Systems approach
• error prone situations
• Focus on multiple contributing factors not just
  the actions of the individual
• Redesign the process improve safety

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Nuclear Power Industry
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Airline Industry
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• 1 in 3 million chance of dying on an aeroplane
  between the UK and the USA
• 1 in 300 chance of dying in hospital
• CMO

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• It sometimes feels like we design patient safety
  problems into our systems in the NHS

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• It sometimes feels like we design patient safety
  problems into our systems in the NHS

or that systems and practices have evolved over
time to conspire against us and our patients
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Background

• Created following the publication of
• An organisation with a memory, which looked at
  learning from adverse incidents in the NHS
• and
• Building A Safer NHS for Patients, which set out
  the governments plans to address AOWAMs
  recommendations.

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Purpose of the NPSA

• To promote a consistent approach to improving
  patient safety throughout England and Wales
• To promote local and national reporting of
  incidents
• To promote local and national learning from
  when things go wrong
• To develop national solutions for local
  implementation
• To improve PATIENT safety by reducing the risk
  of harm through error
• (source Building a Safer NHS for Patients)

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About us

• Not a regulatory body
• Not performance management
• No disciplinary powers
• We work through facilitation and collaboration
  seeking to build the will, skill and capacity to
  engage with the national agenda on patient safety

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Definitions

• What do we mean by patient safety?

The processes by which an organisation reduces
the risk and occurrence of harm to patients as a
result of their healthcare
What is a Patient Safety Incident (PSI)?
Any unintended or unexpected incident(s) that
could have or did lead to harm for one or more
persons receiving NHS funded healthcare This is
also referred to as an adverse event/incident or
clinical error, and includes near misses
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National Reporting and Learning System

• First healthcare reporting system on this scale
  anywhere in the world
• IT and/or web based system that records patient
  safety incidents
• Connecting NHS trusts/Local Health Boards, to
  NPSA database

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Aims
Assimilate other PS information
Store anonymised information
NHS staff / Public / Patient / Reporting
Identify and record PSIs
Help the NHS to learn from PSIs

• Preventative
• Solutions

Inform development of national solutions
Not punitive
Supplement local reporting learning
Minimise reporting burden
Discover patterns contributing factors
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What are solutions?

• They are ways in which the risk of patient
  safety incidents may be minimised

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What would you do?
JFK International Terminal Mens Restrooms

• A) Hire an attendant to monitor and reprimand
  less hygienic users
• B) Periodically plot spillage area on an X-bar
  chart, look for special causes
• C) Double the size of the fixtures
• D) Etch the image of a fly on the porcelain

Source Wall Street Journal
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JFK International terminal mens restrooms
d) etch the image of a fly on the porcelain
Source Wall Street Journal as used by John
Grout, NPSA Seminar 17 January 2003
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Which dial turns on the burner?
Natural Mappings
Stove A
Stove B
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Water
Lignocaine
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If you want to be clear make sure you always use
spell check
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• Aoccdrnig to a rscheearch at Cmabrigde
  Uinervtisy, it deosn't mttaer in waht oredr the
  ltteers in a wrod are, the olny iprmoetnt tihng
  is taht the frist and lsat ltteer be at the rghit
  pclae. The rset can be a total mses and you can
  sitll raed it wouthit porbelm. Tihs is bcuseae
  the huamn mnid deos not raed ervey lteter by
  istlef, but the wrod as a wlohe.

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In conclusion
We cant change the human condition, but we can
change the conditions under which humans
work Prof James Reason
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Build a safety culture
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Remember to handle hazardous substances with
extreme care.
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• Oops no ramp.

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Promote reporting especially those that have
the potential to harm
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Implement solutions to prevent harm design out
error
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When faced with adversity, use your initiative
wisely
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