The Pharmaceutical Journal
Vol 280 No 7505 p696
7 June 2008

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National Patient Safety Agency

Reducing harm — a work in progress

Innovation and technology will increasingly play a major role in delivering safer healthcare, Ann Keen, junior health minister in England, told delegates at the Patient Safety Congress.

“Coding for success” was published in 2007, calling for a barcoding system to be adopted throughout healthcare and already progress is being made. The Government Secure Intranet (GSI) system is investigating automatic identification and data capture. Barcodes and radio frequency identification would provide NHS staff with the tools they need to ensure patient safety, said Ms Keen.

“ We need to give the right care to the right patient at the right time,” she said and pointed out how interruptions can lead to error that technology could help to reduce.

GSI has carried out 100 tests in the past year but there was still much to do, she said.

“Many items leave the manufacturer with no codes or no standard codes.” This year the Government would work on this, she added.

David Cousins, head of safe medication practice at the NPSA, welcomed the news. “I’m looking forward to the day when barcode technology is at the bedside,” he said. “Medicines are barcoded now but it would be a case of using the barcodes on the medicines, linking it with electronic prescriptions and saying: ‘This is what I am about to administer. Is it correct?’ It would be really good as you are not even dependent on another fallible human being. Barcoding is the next big step up.”

Video games technology is also being explored as a way to increase safety. A technology strategy board has been set up by the Government, said Steve Jarvis, a learning consultant for the games company VEGA.

Alongside TriSim and the universities of Birmingham and Coventry, VEGA is testing out how game prototypes could help improve the attitudes and behaviours of staff towards infection control policies.

“Triage trainer”

Mr Jarvis reported on results from using a “Triage trainer” game to test health staff skills. It uses a bomb explosion scenario. “They get instant feedback and the chance to practise again so you get improvements quite quickly,” he said.

The usefulness of the game was assessed by comparing two groups of nurses — one that had used the trainer game and a control group. The nurses went through a “real” test with eight actors representing particular injuries. Seventy per cent of those in the games group gave correct solutions to all the triage scenarios set yet only 28 per cent did in the control group, he said. Other work was ongoing on games to change attitudes.

MRSA progress

David Nicholson, chief executive of the NHS, praised political emphasis on the safety agenda. While there has been much criticism over the high number of targets and change in the NHS in recent years, the challenges set by politicians on healthcare-associated infections means that the health service was making progress on meticillin-resistant Staphylococcus aureus and Clostridium difficile.

Prime Minister Gordon Brown visited the congress to praise healthcare staff for their efforts on infections and other measures, pointing out that in the past year, rates of both had fallen. “Over time we are going to be screening people coming in with MRSA. We will be doing more to protect them,” he said.

But with most organisational change out of the way, Mr Nicolson continued, the question now was how to use the capacity of all the reforms? It was clear from Lord Darzi’s review that “the importance of quality is the organisational priority of the NHS”, he said.

This summer’s NPSA National Patient Safety Campaign would allow trusts to make decisions on improving quality themselves. “The important thing about this is that it will be bottom up. The way to kill a campaign like that is to make it a national target,” Mr Nicolson said.

Preventing avoidable deaths

The 100,000 Lives Campaign in the US had shown the effectiveness of such an approach, said Don Berwick, president of the US Institute for Healthcare Improvement.

Some 3,100 hospitals voluntarily joined up, all instigating six “campaign planks” across their sites, leading to the prevention of more than 122,000 avoidable deaths. Using bundles of care based on evidence-based best practice and ensuring that all staff were involved so that improved care reached hundreds of thousands of patients was crucial to its success. “Safety needs to be the wallpaper,” he said.

He said it was vital the NHS got rid of a culture of “blame, secrecy and injury” and must do so using “openness, honesty, forgiveness and teamwork”. Leaders must be at the forefront of this change which, instead of costing money, could save some with reduced bed days and healthier patients.

He praised Scotland’s National Patient Safety Programme. Initially this is focusing on improving safety in hospitals but will move on to community care.

Phase 2 of the UK’s Safer Patients Initiative (SPI) was now happening in the UK involving 20 trusts — with “spectacular results”, said Dr Berwick.

North Bristol NHS Trust is one of those 20. Frank Hamill, clinical audit manager for the trust told delegates how to measure patient safety improvement. His trust had collected data on agreed operational definitions. These were descriptions of what to measure.

“These must be easily understood by the people collecting the data. Always test them before you apply them across the trust,” he advised. Staff must be aware that they would not necessarily get good results — as North Bristol had found on some measures.

Measurement data then needed to be translated into information that would show if the trust’s improvement strategies were working, he said.

The SPI started at the trust in March 2007. North Bristol has three intensive care units across two sites. Compliance with the “ventilator-acquired pneumonia” bundle at the Frenchay ICU was only 40 per cent at the beginning, said Mr Hamill. “We started some work and managed [to raise it] to 80 per cent but we had some very negative consultant feedback.”

Some were very hostile to the American-style system that was coming in, and some staff followed the consultants’ lead. This resulted in a dip in compliance.

Regular feedback to staff was essential to prevent staff withdrawing from patient safety initiatives. “Feedback gives staff a sense of power because they can see the outcomes of their actions.”

Mike Davidge, senior adviser for the NHS Institute for Innovation and Improvement urged delegates to sign up to the Patient Safety Campaign if they worked in England or to get involved in their own campaigns if they lived in Wales or Scotland. He called on managers to join Leadership for Improving Patient Safety.

“This is specifically aimed at your senior leaders to help them move their mindset from a judgemental approach to one focused on ways to improve,” he said.

Tackling “the enemy within”
Sir Bruce Keogh, NHS medical director, reported that patient safety was still in second place to balancing the books in the NHS. This was despite the fact that the health service was now in the black for the first time ever. He said trusts should empower junior doctors to become “change agents” on safety.

Looking at his own attitude to heart operations as a surgeon, Sir Bruce revealed his own perspective had been that a certain number of patients dying was inevitable. Such as attitude was “the enemy within”, he said. NHS staff had the same idea about infection — that it is inevitable. It is important to try to change this, he added.