Lessons Learned in the National Patient Safety Agency in UK

Lessons Learnt by the National Patient Safety Agency14th December 2007Dr Helen GlenisterDeputy Chief ExecutiveNPSAOverview• Background to NPSA• National Reporting and Learning System in England and Wales• Using information to make change• Approaches to Solutions Development• Involvement of PatientsEngland and Wales- No. Population: 53,728,800- No. of Organisations in NHS: 429- No. of consultations:Over 1.5 million patients and their families are in contact with NHS services every day - No. of Staff: 1.3 million people employed in NHSNPSA: Background• An organisation with a memory (2000)• Building a safer NHS for patients (2001)• Safety First: A report for patients, clinicians and healthcare managers (DH 2006)The National Reporting Learning System• All NHS organisations (acute, mental health and primary care) are connected• Confidential reporting• Incidents are mainly reported electronically and uploaded from Local Risk Management Systems 99%• Direct ReportingNRLSChange of Direction• Rapid reporting of Patient Safety incidents that involve serious patient harm and death within 36 hours of the report.Purposes of the National Reporting and Learning System• To identify similar incidents and learning to those reported through rapid reporting• Follow-up of similar incidents • Identify trends and patterns for priority action in the future• Surveillance of incidents related to risk prevention strategies• Evaluate and inform policy developmentNumber of patient safety incidents reported by quarter, November 2003 to June 2007Source of Notification to NRLS, by quarter July 2006 to June 2007Source of 20062007NotificationJul - SepOct - DecJan - MarApr - JunNo. of No. of No. of No. of %%%%IncidentsIncidentsIncidentsIncidentsLRMS200,17899.0185,62098.5217,75298.5239,65798.8Eform1,9401.02,5381.32,6851.22,1180.9Community 620.02290.15270.28200.3PharmacyTotal202,180100.0188,387100.0220,964100.0242,595100.0Source: Data is based on date the incident was reported to the NRLS.Document Outline

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