1. Oxford AHSN Patient Safety Collaborative November 2014 1

2. What is patient safety? Broadly the reduction of harm Incident? Adverse events? Or major failures in care with implications for patients? Or the risk of such events? Building a safer system Safety as an aspiration in a hazardous environment This has implications for what we do and how we approach the programme 2

3. Oxford Region Partnerships Patients and carers Patient Safety Federation South of England Mental Health & Community PSC Patient Safety Academy AHSN Partners – Universities, NHS and Industry 3

4. Oxford AHSN Patient Safety Landscape Sepsis/ Infection Medicines management Human Factors Avoidable Harm/ Death Falls Prevention Malnutrition Board engagement Patient Experience Pressure Ulcers UTI prevention Patient Safety Federation  South of England Patient Safety in Mental Health Collaborative  Patient Safety Academy  Oxford AHSN Clinical Networks  Oxford AHSN Clinical Innovation Adoption programme  OUHT  OHFT  Bucks New University  Oxford Brookes University  University of West London  4

5. Prioritisation Sources: National priorities (essentials – assume this is leadership and measurement) Local priorities (Trusts, commissioners and clinical networks) chosen from: Falls Pressure ulcers Nutrition and hydration Acute kidney injury UTIs and other infections Missed and delayed diagnosis Failure to return to mental health wards Deterioration of patients Medication safety Sepsis Handover & discharge 5

6. Prioritisation Sources: National priorities (essentials – assume this is leadership and measurement) Local priorities (Trusts, commissioners and clinical networks) chosen from: Falls Pressure ulcers Nutrition and hydration Acute kidney injury UTIs and other infections Missed and delayed diagnosis Failure to return to mental health wards Deterioration of patients Medication safety Sepsis Handover & discharge Process to agree future priorities 6

7. Measurement & Evaluation Our major challenge will be to demonstrate change (rather than activity) This has bedevilled all safety programmes in NHS Measurement is therefore number 1 priority because: It focuses minds and priorities It has been the major headache for all safety programmes The time taken to get measures in place has been consistently underestimated It is essential for the programme teams to function effectively It is fundamental to evaluation We should not initiate any programme in early phase unless measures are already available 7

8. Types of safety initiative Clinical topic programmes Thematic clinical programmes which address issues which cross the best care programmes (e.g. handover, transitions etc) Thematic programmes which address organisational and system level issues (e.g. regulation) And others …. In the longer term we need to build a safer system 8