1. Safer Systems for Safer Healthcare Dr. Maureen Baker CBE DM FRCGP Clinical Director for Patient Safety NHS Connecting for Health

2. Overview The NHS The NPfIT Development of patient safety movement Safety management systems NHS CFH Clinical Safety Management System Experience so far Next steps

3. The UK National Health Service UK population 60 Million Almost 1 Million consultations with GPs every working day 100,000 people in hospital every working day NHS covers every health sector 4 country model 750 Million prescription items from general practice in England per annum

4. The National Programme for IT in the NHS in England Established 2002 Has a number of central features and programmes (National Spine; Choose and Book; GP2GP; National Care Record Service; Picture Archive and Communications Service; Electronic Transfer of Prescriptions) Local Service Providers Estimated cost US$25 Billion over 10 years (contracts, training and implementation) Being delivered by NHS Connecting for Health

5. Some definitions Patient Safety – freedom from accidental harm to individuals receiving healthcare Patient Safety Incident – an episode when something goes wrong in healthcare resulting in potential or actual harm to patients

6. NPSA Report on Safety in NPfIT National Patient Safety Agency established 2001 Report commissioned 2004 Conducted by NPSA Risk Advisor

7. Report Findings Not identifying safety as a benefit to drive the programme No formal risk assessment No formal safety management system Reliance on clinicians to instinctively address patient safety problems NPfIT not addressing safety in structured, pro- active manner and other safety critical industries would

8. Safety Critical Industries with Safety Approach Aviation Railways Oil and Gas Construction Nuclear Military

9. NHS CFH Clinical Safety Management System Based on principles of IEC 61508 Light touch, yet robust Three key pieces of documentation Practical and pragmatic – in place for almost 4 years Supplemented by established Safety Incident Management Process

10. NHS CFH CSMS Deliverables Hazard assessment Safety case Safety closure report Clinical Authority to Release (CATR) (Includes ‘caveats’)

11. Safer Care, i.e.: x > y = a+b What we are trying to achieve? Risk Baker, M et al, Safer IT in a Safer NHS: Account of a Partnership, The British Healthcare Computing & Information Management, Vol. 23 No. 7 Sept 2006

12. Safety Incident Management System Incidents related to Health IT reported and logged Assessed and managed by Clinical Safety Group (clinicians and safety engineers) Aim to ‘make safe’ (remove potential for harm) with 24 hours Around 430 incidents reported since 2005 97% made safe within 24 hours

13. NHS IT – What can go wrong? Patient identification (wrong notes, wrong results, wrong procedure) Data migration (re-start discontinued drugs, incorrect preservation of meaning) Data mapping (mapped to non-identical preparation, eg long-acting or slow release) Data corruption (over-writing of info on NHS Spine)

14. Safety Workstreams in NHS CFH Safe IT systems (as safe as design and forethought will allow) Safety Incident Management Process Training for accreditation and safe implementation Technology for patient safety

15. Accredited Clinician Programme Dedicated training in principles of safety and risk as applied to Health IT In 4+ years trained over 550 delegates, approx 60% are clinicians Clinicians must be registered with appropriate regulatory body Supports clinical input to activity by appropriately trained and qualified clinicians

16. Passing the Safety Baton NHS CFH (and Software Providers) Support from: Clinical Safety Group Clinical Authority to Release Implementing organisation (Hospitals Pharmacists, GPs etc.) Support from: Internal Risk Team Safer Design and Development Safer Implementation Passing the Baton – Ownership passed from NHS CFH to NHS

17. Implementation Network Aimed at individuals in NHS Trusts with direct responsibility for significant IT implementations Develop a community of interest Explicitly designed to facilitate networking and peer support Dedicated website Buddying Could be used in support of ‘User Standard’

18. Technology for Patient Safety Right Patient Right Care (tracking technologies – RFID; wristband datasets; NHS number) Safer prescribing (prompts + alerts, tallman) Safer handover (core dataset) Electronic risk assessment tool for VTE Tracking of results Deteriorating patients

19. Design and the NHS “The NHS is seriously out of step with modern thinking and practice with regards to design …. And also fails to understand what design thinking can bring to an organisation …. A direct consequence of this has been a significant incidence of avoidable risk and error” Department of Health & Design Council, Design for Patient Safety Report

20. Building a House

21. Next steps Focus on design and human factors for inherently safe systems Support implementation of standards (NHS and international) for suppliers and users Passing the safety baton Identification and safe implementation of technology for safer care

22. National Programme for IT in NHS “ The National Programme is not just an IT programme, but a patient safety and clinical governance programme” Gordon Hextall, Chief Operating Officer NHS Connecting for Health

23. Conclusion Healthcare is a safety critical industry IT systems don’t deliver care, but are used by clinicians in the delivery of care Good safety practice requires proactive work – systems as safe as design and forethought will allow Also reactive systems to detect and manage errors All encompassed in CSMS and within emerging Standards