National Patient Safety Agency Working towards a national surveillance system for patient safety The National Reporting and Learning System and the Patient Safety Observatory Sarah Scobie Head of Observatory National Patient Safety Agency UK

To cover up is unforgivable To fail to learn is inexcusable To err is human To cover up is unforgivable To fail to learn is inexcusable Sir Liam Donaldson Chief Medical Officer England

Purpose of the NPSA Special health authority with mandate to: implement a national reporting system for patient safety incidents collect and appraise information to promote patient safety provide advice and guidance and monitor its effectiveness promote research which contributes to patient safety report and advise Ministers on matters affecting patient safety The NPSA role includes…. and the report concentrates on three key areas: First, it reports on early data from our National Reporting and Learning System Second it describes how we bring together data from the NRLS and a range of other sources to understand and characterise patient safety issues Third it gives examples of how data from these sources is of value in helping us to make the NHS safer.

Overview The National Reporting and Learning System The Patient Safety Observatory: what is it and why do we need it? The Observatory work programme

The National Reporting and Learning System (NRLS) Confidential reporting database Incidents are reported electronically – 99% come from Local Risk Management System Analysis of data at national level to identify trends and patterns provide feedback for local action inform NPSA work programmes

Number of incidents and reporting trusts

Approaches to analysis of NRLS data Routine monitoring reports Thematic analysis Ad hoc analysis Exploratory Reviews of selected incidents Data mining

Routine and thematic reports Trust feedback reports Quarterly overview Thematic reports

Ad hoc analysis Requests from NHS clinicians and risk managers, and relating to current NPSA projects Use of categorical data supplemented by sophisticated text searching tool Examples during one week: epidurals, following fatal incident, to inform an NPSA fast track project on epidural infusions chairs, for an external enquiry Midwifery and Obstetrics, for Litigation Authority event on maternity risk management screening tests for Down's Syndrome, following software issue identified in a trust systemic dermatology treatments blood glucose monitors, following issue identified by the regulator for medical devices wrong route administration of oral liquid medicines, to support the preparation of a patient safety alert

Systematic review of incidents Richness of NRLS data in free text descriptions review from clinical perspective adds value Huge volumes of data – sampling by specialty and incident type Tools to support robust and consistent review of data supported by guidance decision tree for follow-up action

Data-mining Looking for small localised patterns in the data Pattern-search Looking for small localised patterns in the data Able to look through high-dimensional data (categorical and free text) Able to pick out small unknown patterns that may represent a trend in patient safety Model building and hypothesis testing

Incident data not the only source Why do we need a PSO? Incident data not the only source Systematic surveillance and analysis of NRLS and other data 1) The National Reporting and Learning System is a fundamental source of data to understanding patient safety. However, on its own it does not give the whole picture of what does or could lead to patient harm. This is because incident reporting systems are for example not comprehensive – there is a gap between what occurs and what is reported cannot provide some of the detail that can be provided by other reports (e.g. detailed root cause analysis) Therefore, incident reporting needs to be part of a broader approach to surveillance and monitoring. The findings from incident reporting musty be considered alongside a range of data so that we can build up a fuller picture. 2.) Many agencies are already involved in collecting and using information relevant to patient safety but the information not always used to full potential. The healthcare system as a whole could make better use of data sets to explore safety, even if such existing data collections were designed for different purposes. The Patient Safe Observatory works with partners from across a whole range of other organisations, that can help us to assess a problem. This might involve seeing whether other data sets are identifying similar issues, it might help tell us something additional about incidents identified in the NRLS; it might be that we need to access the knowledge and understanding of relevant experts, such as Royal Colleges; or it may be that we need to access relevant patient safety research literature. 3.) Various datasets will help to generate hypotheses, to analyse data and to implement change

Settings of incidents reported to the NRLS Care setting Total Percent Acute/general hospital 441,519 72.2 Mental health service 86,697 14.2 Community nursing, medical and therapy service (including community hospital) 57,029 9.3 Learning disability service 19,534 3.2 General practice 2,636 0.4 Ambulance service 2,356 Community pharmacy 1,373 0.2 Community and general dental service 179 < 0.1 Community optometry/optical service 8 611,331 100.0 Source: Reports in the NRLS database up to 31 March 2006

Trend in reporting rates with time since connection to NRLS

Patient Safety Research Other datasets. Clinical negligence MHRA Hospital Episodes GP Databases Patient Safety Research OTHER ORGANISATIONS Surveillance & Monitoring OBSERVATORY PRIORITISATION Other confidential reporting systems SOLUTIONS NRLS EVALUATION Intelligence Healthcare Commission Expert Groups Patient/Public DH/Ministers Interest Groups etc. NHS Feedback & Bounceback R&D Research Public/Patient eForm PATIENTS/ PUBLIC

The Patient Safety Observatory at Work : MRI scanners NRLS data: 500 reports; 31 related to implants; five pacemakers, one implantable defibrillator, one heart valve and three aneurysm clips went undetected PSO: Litigation relating to pacemaker/MRI fatality; 200 incidents reported to medical device regulator; local visits: frontline staff depending on constant vigilance rather than safer systems Prioritisation process: report to NPSA Board this month

PSO at work: collaboration with other organisations Hospital episode statistics – developing patient safety indicators based on AHRQ Clinical negligence: NHS Litigation Authority and medical negligence organisations Safety culture and processes: NHS staff survey

Indicators from administrative data replicate AHRQ analysis for a sub-set of indicators mapping coding definitions to ICD10/OPCS4 age and sex standardised indicators derived at national and trust level, as per specifications validation: length of stay and mortality (cases compared with matched controls) comparison with US results

Preliminary results: rates per 1000 discharges Indicator England US Death in low mortality DRGs 0.7 Decubitus ulcer 5.7 24.7 Iatrogenic pneumothorax 0.2 0.8 Infections due to medical care 0.1 2.3 Postoperative hip fracture 0.3 Postoperative sepsis 16.3 11.8 Assisted delivery 45.3 237.8 Unassisted delivery 21.7 86.2 Caesarean delivery 2.0 5.6

Preliminary results: excess length of stay (days)* Indicator England US Death in low mortality DRGs - Decubitus ulcer + 11 +4 Iatrogenic pneumothorax +6 Infections due to medical care +10 Postoperative hip fracture + 23 +5 Postoperative sepsis + 13 +11 Assisted delivery + 0.6 +0.1 Unassisted delivery + 0.5 Caesarean delivery + 0.2 +0.4 * Cases vs matched controls

Patient Safety Observatory - summary Systematic analysis No one source of data is sufficient Collaboration between relevant organisations Results: Investigating and reporting back Better use of existing data Path to integrated approach to patient safety surveillance

Thank you sarah.scobie@npsa.nhs.uk