1. Improving Patient Safety on the Wards: Introduction Linda Watterson Programme Manager Evaluating and Improving

2. The size of the problem u 78% EU citizens think medical errors important problem in their country (Eurobarometer) u 44 – 98,000 deaths annually caused by medical error (To err is human) u Adverse events occur in around 10% of hospital admissions, or about 85,000 adverse events per year. (An organisation with a memory) u Spain, France and Denmark have similar figures. Similar types of intervention related adverse event happen in all health care systems despite different organisational and financial systems

3. The patient perspective u Patient evaluation of care u Patient involvement u Digital Stories www.patientvoices.org.uk

4. The nursing contribution u ‘nursing staff can provide their hospital with information about the organisation, management and resourcing of care, that can be used to improve patients’ experiences’

5. Views from the sharp end of care u Blame culture u Feedback u Raising concerns

6. Views from the sharp end of care u Competing priorities u Workload u Staff deployment

7. The two words ‘information’ and ‘communication’ are often used interchangeably, but they signify quite different things. Information is giving out; communication is getting through. Sydney J.Harris

8. The 3-bucket model for assessing risky situations (Reason, 2005) 1 2 3 SELF CONTEXTTASK

9. u Human factors

11. Leadership Culture Communication Feedback Targets Priorities Equipment Professional development Planning Capacity management Workload Staffing Skill-mix Health & Safety Institutional contextThe clinical team Organisation &management of care The individual healthcare worker Working environmentThe patient Blunt’ end of care‘Sharp’ end of care Decisions made hereImpact here Latent failures Active failures (Based on Nolan, 2000; Reason et al 2001)

12. Antecedents, determinants and components of safety performance (Adapted from : Neal & Griffin, 2002) ANTECEDENTSDETERMINANTSCOMPONENTS Management commitment/leadership Communication Rules/procedures/protocols/guidance Appreciation of risk(s) Involvement SafetyKnowledge & SkillSafety Compliance Work environment Climate MotivationSafety Participation Supportive environment Priority of safety Personal priorities Compliance and participation represent behaviours that individuals perform whilst at work. Safety compliance describes the core activities that must be carried out to maintain safety; safety participation describes behaviours that do not directly contribute to safety, but which help to develop an environment that supports safety. If an individual does not have sufficient knowledge and skill to comply with safety regulations or participate in safety activities, they will not be able to perform these actions. If they do not have sufficient motivation to comply with safety regulations to participate in safety activities they will choose not to carry out these actions. Safety climate is one of many antecedents of safety performance, for example, management commitment and leadership are felt to play an important role in shaping workers perceptions of the safety climate in their organisation

13. Management commitment: Perceptions of management’s overt commitment to safety Safety rules & procedures: Views on the efficacy and necessity of rules & procedures Personal priorities: The individuals view of their own health & safety management and the need for feel safe Communication: The nature and efficiency of health & safety communications within the organisation Priority of safety: The relative status of health & safety issues with the organisation Involvement: The extent to which safety is a focus for everyone and all are involved Supportive environment: The nature of the social environment at work, and the support derived from it Personal appreciation of risk: How individuals view the risk associated with work Work environment: Perceptions of the Nature of the Physical environment The dimensions covered by the Safety Climate Tool

14. Dimension, Descriptor, Associated Questions  Dimension: Perceptions of management’s overt commitment to safety.  Descriptor: Management act decisively when a safety concern is raised  Questions: - Management acts only after accidents have occurred - Corrective action is always taken when management is told about unsafe practices - In my workplace management acts quickly to correct safety problems - In my workplace management turn a blind eye to safety issues - In my workplace managers/supervisors show interest in my safety - Managers/supervisors express concern if safety procedures are not adhered to

15. REASON, 2005

16. Strengthening the nursing contribution u Reporting and learning –Value of reporting –Valuing the nurses understanding of safety issues u Developing positive cultures –Blame culture –Empowerment –Training opportunities –Improving communication –Work environment Staffing level /skill mix /workload issues Use audit and benchmarking u Sharing solutions –Valuing the nurses role –Sharing best practice –Tools and techniques u Patient / consumer involvement

17. Proposed approach u Focus for patient safety u Support and strengthen the value of the nursing voice u Provide members with appropriate tools to review safety at all levels u Provide learning and development resources and opportunities u Consider the value of the patient voice for learning and challenging

18. Sharing best practice Contact: linda.watterson@rcn.org.uk

19. References and useful reading u Anderson DJ. Webster CS (2001) A systems approach to reduction of medication error on the hospital ward Journal of Advanced Nursing 35 (1) 34 – 41 u Attree M (2007) Factors influencing nurses’ decision to raise concerns about care quality Journal of Nursing Management 15 392 - 402 u Currie L, Watterson L, (2007) Challenges in delivering safe patient care. A commentary on a quality improvement initiative Journal of Nursing Management 15 (2) 162 - 168 u Department of Health Expert Group An organisation with a memory: report of an expert group on learning form adverse events in NHS Chairman :Chief Medical Officer London: The Stationery Office 2000 u http://ec.europa.eu/health/ph_information/documents/eb_64_en.pdf u King L Macleod Clark J. (2002) Intuition and the development of expertise in surgical ward and intensive care nurses Journal of Advanced Nursing 37 (4) 322 – 329 u Kohn LT Corrigan JM Donaldson MS eds To err is human: Building a safer health system. Washington, D.C. National Academy Press 2000 u http://www.saferhealthcare.org.uk/ihi http://www.saferhealthcare.org.uk/ihi u Mrayyan MT, Huber DL (2003) The Nurses Role in Changing Health Policy Related to Patient Safety JONA’s Healthcare Law, Ethics and Regulation 5 91 u Meurier CE (2000) Understanding the nature of errors in nursing: using a model to analyse critical incident reports of errors which had resulted in an adverse or potentially adverse event Journal of Advanced Nursing31 (1) 202 - 207 u Sorlie V, Torjuul K, Ross A, Kihlgren M (2006) Satisfied patients are also vulnerable patients – narratives from an acute care ward Journal of Clinical Nursing 15, 1240 – 1246 u Storr J TopleyK, Privett S. (2005) The ward nurses role in infection control Nursing Standard 19 (41) 56 – 64 u Sdottir H A, Bjornsdottir K (2008) Nursing and patient safety in the operating room Journal of Advanced Nursing 61 (1) 29 - 37 u Walker AC, (2002) Safety and comfort work of nurses glimpsed through patient narratives Internationaol Journal of Nursing Practice 8: 42 – 48 u West E, Barron DN, Reeves R (2005) Overcoming the barriers to patient – centred care: time, tools and training Journal of Clinical Nursing 14, 435 – 443 u www.npsa.nhs.uk www.npsa.nhs.uk u www.who.int/patientsafety www.who.int/patientsafety

20. Ref: Storr J. et al The nurses role in infection control Nursing Standard 19 (41) 22 June 2005 Key action areas for ward nurses in preventing infection