Healthcare organizations from Scotland, UK and internationally, working to improve patient safety through various initiatives, projects and programmes.
The Scottish Patient Safety Programme
The Scottish Patient Safety Programme, working in partnership with the Institute of Healthcare Improvement, is being implemented in every acute hospital in the country. The initial goals are to drive improvements in:
- Critical Care
- General Ward
- Medicines Management
- Scotland’s Successful National Approach to Improving Patient Safety in Acute Care
- The Scottish Patient Safety Programme
The Scottish Patient Safety Fellowship Programme
The Scottish Patient Safety Fellowship Programme was introduced to develop and strengthen clinical leadership and improvement capability in NHSScotland in order to support the implementation of SPSP. The Fellowship Programme is led by Healthcare Improvement Scotland, in partnership with NHS Education for Scotland (NES) and NHSScotland territorial NHS boards.
NHS Territorial Boards
All territorial boards have a statutory obligation to protect their patients and staff from avoidable harm.
They also have a number of key responsibilities to patient safety, including:
- To encourage incident reporting by all NHS staff,
- To create a ’just’ culture’ in which incident reporting is clearly separated from disciplinary processes,
- To analyse reported incidents and consider information from frontline staff when planning and implementing change.
- To clarify what is expected of staff after a patient safety incident, and what support is available to deal with it.
Healthcare Improvement Scotland (HIS)
Healthcare Improvement Scotland co-ordinates or leads a number of patient safety-related programmes of work. They work in close partnership with NHS Boards and other agencies to:
- Help improve risk management,
- Raise awareness of patient safety
- Promote incident reporting
The organisation’s 2006 report ‘Safe Today – Safer Tomorrow’ contained a number of findings with important implications for patient safety:
- Adverse events are commonly under-reported
- Reporting systems are limited and often have poor usability
- When incidents are reported, responses are inconsistent and actions often limited.
NHS Education for Scotland (NES)
NES is committed to developing an integrated educational partnership framework that will support patient safety initiatives across NHS Scotland. The interested reader can find examples and more information about a range of activities and educational resources on our patient safety website.
NES commissioned the Nursing Numeracy project to develop a standardised numeracy assessment tool for nursing staff 'at point of registration’ to their profession.
Safer Patients Initiative (SPI)
The Safer Patients Initiative (SPI) was one of the first organised attempts to improve patient safety in the UK. It was commissioned by the Health Foundation to address the problem of preventable harm in secondary care. Twenty four hospital sites participated during two phases that ran from 2004 until 2008.
Safer Patients Initiative aims
The aim of phase one was to reduce the number of adverse events in the first four pilot hospital sites by 50%.
The initial four sites were to achieve this aim through a ‘change package’ designed by the Institute for Healthcare Improvement. This package consisted of change on three levels:
Clinical: Multiple, evidence-based interventions applied to five clinical areas
Staff: Staff training in quality and safety improvement methodologies
Leadership: Establishing specific roles for the Chief Executives and senior executive teams.
The aims of phase two were to reduce the mortality rate by 15% and to reduce adverse events by 30% in twenty four hospitals over the two year period, 2006 to 2008.
The Health Foundation
The Health Foundation is an independent charity based in London that aims to improve the quality of healthcare across the United Kingdom and beyond. They have commissioned, undertaken and/or supported a large number of patient safety and quality improvement projects. Various useful reports, evaluations and projects can be accessed on their website.
The initiative helped to deliver reported improvements in a number of patient safety related areas. Interested readers can view examples from the four hospital sites which participated in Phase one:
Wales: North West Wales NHS Trust
Reported that rates of ventilator-acquired pneumonia and the average length of Intensive Care Unit admissions decreased significantly during the initiative.
England: South Eastern Health and Social Care Trust
A medication reconciliation system was developed and implemented. A key feature was that it linked to primary care. At the time of the initiative, it was reported that drug kardexes of >90% of patients admitted to hospital were appropriately reconciled.
England: Luton and Dunstable Hospital NHS Trust
An early warning score system (MEWS) was introduced in hospital wards which was reported to be associated with a significant decline in cardiac arrests and standardized mortality.
Scotland: NHS Tayside
The reported rate of adverse events was reduced by 75% and hand hygiene compliance increased to >95% at the time of the initiative.
The experience and lessons from the SPI have several implications for future initiatives, for example:
- Health care workers may not be aware of the scale of the patient safety problem or ongoing efforts to improve the situation
- Additional training may be required for the vast majority of health care workers to help them contribute effectively to improvement initiatives
- It is essential that organisations learn from the ‘front line’. One way in which this can happen is through the formal reporting of patient safety incidents.
- Existing reporting systems may have to be improved to enable health care workers to use them more effectively.
Many health care organizations from across the world are attempting to improve patient safety through various initiatives, projects and programmes. Two examples include:
- USA, California. Kaiser Permanente implemented a matching medication and patient bar coding system as an additional safety check before drug administration. Early results suggest adverse drug events may have been reduced by 50%.
- Australia, Sydney. Liverpool Hospital introduced Rapid Response Teams who respond and assess patients that shows early signs of deterioration. The frequency of cardiac arrests was reduced by 65% and overall mortality by 24%.
Contributing to the international effort to improve patient safety NHS Education for Scotland.
Clinical Governance and Risk Management Reviews Healthcare Improvement Scotland.
Leading on Quality Improvement and Patient Safety in Community and Primary Healthcare Services Healthcare Improvement Scotland.
NPSA resources for patient safety National Patient Safety Agency.