1. Clinical Risk Unit University College London International Perspectives Feedback from the review board Charles Vincent Clinical Risk Unit University College London

2. Clinical Risk Unit University College London Adverse event studies u 3-16% adverse event rate in US and Australia u 10.0 % cases with adverse events in UK u 10.7 % adverse event rate u 30% events lead to moderate or greater impairment to patient u Half of adverse events cases preventable

3. Clinical Risk Unit University College London To err is human: The Institute of Medicine Report u Establish a national focus to create leadership, research tools and protocols u Identifying and learning from errors through mandatory & voluntary reporting u Raising standards and expectations for the improvement of safety u Creating safety systems inside healthcare organisations through implementation of safe practices at delivery level

4. Clinical Risk Unit University College London Recommendations from the IOM Report u Creation of a Centre for Patient Safety –Set national goals –Develop knowledge and understanding u Identifying and learning from errors –Nation-wide mandatory reporting system –Encouraging voluntary reporting systems –Legislation to protect safety data

5. Clinical Risk Unit University College London Recommendations from the IOM Report u Performance standards and expectations –Focus greater attention on patient safety for »health organisations »health professionals –Drug packaging and drug names u Implementing safety systems –Establishing patient safety programmes –Implementing proven medication safety practices

6. Clinical Risk Unit University College London An Organisation with Memory Recommendations u Introduce a national mandatory reporting scheme for serious adverse events u Encourage a reporting and questioning culture u Introduce a single overall system for analysing and disseminating lessons u Make better use of existing sources of information

7. Clinical Risk Unit University College London An Organisation with Memory Recommendations u Improve the quality and relevance of adverse event investigations and inquiries u Undertake a programme of basic research u Make full use of NHS information systems u Act of ensure lessons learned quickly

8. Clinical Risk Unit University College London An Organisation with Memory Recommendations u Identify and address specific categories of serious recurring adverse events –Reduce deaths from maladministered spinal injections to zero –Reduce negligent harm in obstetrics by 25% –Reduce by 40% serious errors in use of prescribed drugs –Reduce suicide by hanging in mental health patients to zero

9. Clinical Risk Unit University College London An Organisation with Memory Learning from adverse events in the British NHS PAST u Fear of reprisals common u Individuals scapegoated u Individual training dominant u Attention focuses on individual error FUTURE u Generally blame free reporting u Individuals held to account u Team-based training more common u Systems approach to hazards & prevention

10. Clinical Risk Unit University College London An Organisation with Memory Learning from adverse events in the British NHS PAST u Lack of awareness of risk management u Short term fixing of problems u Adverse events regarded as `one-offs’ u Lessons seen as only relevant for team FUTURE u Risk & safety training provided u Emphasis on sustained risk reduction u Potential for repeated events recognised u Lessons may be relevant to others

11. Clinical Risk Unit University College London National Centre for Patient Safety in Switzerland (NCPS) u Identify existing patient safety initiatives u Establish central database of resources and information and research programme u Enhance methods of investigation and analysis u Disseminate lessons learned and initiate risk reduction programmes u Provide support and guidance for patients and staff

12. Clinical Risk Unit University College London Central themes of NCPS u Building on international work, but developing uniquely Swiss programme u Broad strategy and positive approach to patient safety u Systems thinking and interventions u Strong emphasis on organisational culture u Unique focus on supporting and caring for patients and staff

13. Clinical Risk Unit University College London Key tasks in Phase II u Consultation and gaining support from patients and professionals u Integration of patient safety with broad quality initiatives u Debate on the need for an open culture u Balance of immediate improvements and long term re-design of systems u The role of financial and legal pressures

14. Clinical Risk Unit University College London Looking to the future u Potentially the first National Patient Safety Centre in Europe u Balancing local and national systems u Development of international links within healthcare and with other industries u Maintaining a positive patient centred approach