Why should health care organisations connect to the NRLS? Incidents which appear isolated and infrequent to an organisation, may not be on a national scale Lessons can be learned NHS Organisations with similar issues will be matched so that they can be tackled collaboratively Bounceback / feedback of relevant information Data quality issues can be highlighted and dealt with via support from PSM Incidents which appear isolated and infrequent to an organisation, may not be on a national scale Lessons can be learned NHS Organisations with similar issues will be matched so that they can be tackled collaboratively Bounceback / feedback of relevant information Data quality issues can be highlighted and dealt with via support from PSM

Components of the Campaign NRLS to patient safety –Aims to promote a clear and consistent approach –NHS organisations can use it as a reference guide –It will provide a framework for local organisations to develop or review their internal policies, processes and practices regarding patient safety. Being open with patients NRLS to patient safety –Aims to promote a clear and consistent approach –NHS organisations can use it as a reference guide –It will provide a framework for local organisations to develop or review their internal policies, processes and practices regarding patient safety. Being open with patients

The restraint of older people Safe Medication Practice for Children Determining the role of supervised consumption of Methadone in the reduction of accidental overdose Creating A Safer Environment on Acute Psychiatric Wards Burns/scalds arising from hot water in baths/pipes Wrong Site Surgery Use of Non-Latex Products in the Care of Latex Sensitive Patients The identification and management of swallowing difficulties Incorrect matching of patient with aspects of care Standardising the Crash Call Number Use of Hip Protectors to Prevent Fractured Neck of Femur in Acute Care Setting Identification of Visually Impaired Patients by use of stickers on Hospital and GP Records Design for Patient Safety Reducing the Risk of Methotrexate Dosage Error Staff training in the resuscitation of laryngectomy patients Infusion Devices Bowel care management for people with established spinal cord lesions in NHS organisations Clean your Hands Naloxone Provision by Ambulance Trusts Clinician Identifier Stamp Safety Solutions

FUTURE

NHS Care Record Service Model Other data sources NHSnetWWW NRLS NCR Secondary Uses Other data sources LSP

Drivers for HL7 Compliance Develop an HL7 compliant messaging model that accurately captures patient safety incident information. Complement this information with other data needed for aggregated analysis Embed patient safety decision support systems (e.g. guidance, alerts) into HL7 compliant message flows. (e.g. CREDO) Develop an HL7 compliant messaging model that accurately captures patient safety incident information. Complement this information with other data needed for aggregated analysis Embed patient safety decision support systems (e.g. guidance, alerts) into HL7 compliant message flows. (e.g. CREDO)

Planned development for 2004 / 2005 NHS Care Record System (NCRS) –HL7 messaging standard –SNOMED CT –ISB operational standard Scope RCA reporting within the NRLS Develop public / patient reporting Extend to –Private sector –Prisons Continue identifying options for working with other NHS organisations WHO collaboration / international taxonomy of PSIs NHS Care Record System (NCRS) –HL7 messaging standard –SNOMED CT –ISB operational standard Scope RCA reporting within the NRLS Develop public / patient reporting Extend to –Private sector –Prisons Continue identifying options for working with other NHS organisations WHO collaboration / international taxonomy of PSIs

Individual Case Safety Reporting

ICSR Well suited for your current requirements NPSA acknowledges that message development has to be iterative and user-driven Recognises the huge amount of collective effort that has already gone into the ICSR The NPSA wants to actively engage with PSSIG and assist in message development Well suited for your current requirements NPSA acknowledges that message development has to be iterative and user-driven Recognises the huge amount of collective effort that has already gone into the ICSR The NPSA wants to actively engage with PSSIG and assist in message development

NPSA Requirements Model should facilitate incident reporting Extend breadth of PSI categories –Omissions / commission Facilitate use by confidential and anonymous reporting systems Reflect PSIs may occur to a group of patients or no-one at all Model should facilitate incident reporting Extend breadth of PSI categories –Omissions / commission Facilitate use by confidential and anonymous reporting systems Reflect PSIs may occur to a group of patients or no-one at all

Requirements - Bounceback Thank you for submitting your incident report related to infection control. You may be interested to look at the work the NPSA has been doing in this area by clicking on the link below: You may also be interested to look at content on the following sites: NELH: Cochrane Library: Thank you for submitting your incident report related to infection control. You may be interested to look at the work the NPSA has been doing in this area by clicking on the link below: You may also be interested to look at content on the following sites: NELH: Cochrane Library:

Requirements - Feedback (Specific) Trust: Royal Devon and Exeter –Top 5 incident types: ……… etc. –Relevant actions taken nationally on these: ……. ……. etc. –Top 5 clusters detected: Neo-natal unit and hypothermia Burn and cup of tea between 3pm and 5pm ……… etc. Trust: Royal Devon and Exeter –Top 5 incident types: ……… etc. –Relevant actions taken nationally on these: ……. ……. etc. –Top 5 clusters detected: Neo-natal unit and hypothermia Burn and cup of tea between 3pm and 5pm ……… etc.

Requirements - Feedback (Contextualised) Trust: Royal Devon and Exeter Frequency Specialty A&E Dentistry Virology Genetics Obstetrics Peer group average National average

Information Requirements Service area Incident location PSI date / time Country Incident category Underlying causes Contributory factors Actions –Planned or taken –Preventative –Minimised harm Prevented PSI Service area Incident location PSI date / time Country Incident category Underlying causes Contributory factors Actions –Planned or taken –Preventative –Minimised harm Prevented PSI Age Paediatric ward Sex Ethnic category Impairment / disability Specialty MHCPA Harm –Yes / No –Degree –Effect Staff type / status / role

Information Requirements - Medication Stage Medicine incident type Other contributory factors Approved (drug) name Proprietary (trade) name Form Dose and strength Route Stage Medicine incident type Other contributory factors Approved (drug) name Proprietary (trade) name Form Dose and strength Route BNF classification Administration –Intended drug Manufacturer Batch number Manufactured special? Registered EU importer –Re-labelled for UK market Clinical trial

Information Requirements - Devices Type Current location Product name Model Catalogue number Serial number Type Current location Product name Model Catalogue number Serial number Manufacturer Supplier Batch number Expiry date Manufacture date

Wish List Common definition for patient safety / PSI Key requirements Stakeholders –Specialism –Level of involvement Other relevant HL7 messages Synergistic action plan Common definition for patient safety / PSI Key requirements Stakeholders –Specialism –Level of involvement Other relevant HL7 messages Synergistic action plan