Section 5 -

United Kingdom Patient Safety Initiatives Peter Furness, BM BCh, PhD, FRCPath Leicester General Hospital Department of Pathology Leicester , UK

The presence in the UK of the National Health Service, which delivers medical services free at the point of delivery to the entire population, has created a unique platform for the implementation of international developments in patient safety. To achieve this, the National Patient Safety Agency (NPSA) was established in July 2001 with the stated aim of co-ordinating efforts to identify and learn from patient safety incidents. [1] Its intention was to make the National Health Service "an organisation with a memory". However, it has become clear that having a memory is not sufficient; to be effective, such an organisation also needs a sensory system, a data processing system and a motor system which is capable of achieving change. The main sensory system of the National Patient Safety Agency is the "National Reporting and Learning System" (NRLS). [2] This aims to channel irreversibly anonymised information about every patient safety incident throughout the NHS into the NPSA's database. Every hospital (and, increasingly, every primary care provider) is expected to have a risk management database into which reports of patient safety incidents are fed. After some technical teething problems, virtually all NHS hospitals and a growing number of primary care organisations have connections established so that anonymised data from these local risk management systems are fed into the national database. The result is data collection on patient safety incidents on an internationally unprecedented scale. There are, of course, other routes for data input. The NPSA has developed an on-line system for direct reporting of incidents, available to members of the public and to staff who, for whatever reason, are reluctant to report potentially embarrassing information through their local hospital management system. [3] Information also comes from letters, telephone calls, literature searches and so on, but in volume these are dwarfed by the data input to the NRLS. The huge volume of data has caused serious processing problems, for which a variety of strategies have been developed. Within pathology, it rapidly became obvious that relevant patient safety incidents were coded as "a pathology incident" relatively rarely. The majority related to incidents involving specimens on the wards or reports after they have left pathology, and were therefore coded under the relevant clinical discipline or hospital location. Other strategies were therefore needed to extract from the mass of data those incidents relevant to pathology. We cannot assume that information entering the NRLS is complete or unbiased. However, with that caveat, by far the commonest type of patient safety incident reported is in the pre-analytical phase. Errors in specimen identification, delays in transport and specimens disappearing before they arrived at the laboratory are numerically far more significant than incidents occurring within the laboratory. The second commonest problem is post-analytical errors; reports going missing, not being read or acted upon, or misunderstandings in the verbal communication of urgent results. Incidents occurring entirely within the laboratory tend to excite much more concern from pathologists, perhaps as there is a greater sense of personal responsibility. But in relation to overall patient safety it would appear that pathologists should be reaching beyond the laboratory and taking more interest in problems at their interface with other healthcare staff. Processing NRLS data has so far proved extremely laborious. Sophisticated language analysis software has been purchased, but has proved to be of little value within pathology. Incidents can be stratified according to the reports stated impact on the patient, but there are serious problems in the quality of coding by those reporting the incidents, and it is of course possible for a "near miss" with no patient impact to have profound implications for improving healthcare. The National Patient Safety Agency has developed several "motor" functions to try to achieve improvements. The most visible is the intermittent production of patient safety alerts and notices, disseminated throughout the National Health Service, but these can only impact on selected, specific problems. [4] NPSA projects are developed though a formal prioritisation process, with much of the input to that process now coming from the NRLS. For example, one current initiative is targeting improvements in patient identification, a topic of clear relevance to pathology's problems. [5] Considerable effort has been put into changing the culture of the health service. A variety of publications and electronic tools have been produced to persuade staff to avoid the futile attribution of blame where adverse consequences were genuinely unintended, [6] and to concentrate on learning from safety incidents. Training in root cause analysis has been provided to staff in all NHS hospitals, and packages are available on the NPSA website. [7] But there remains a problem in relation to disseminating information about small, everyday improvements in safe practice which are relevant to only a small number of healthcare practitioners. This is commonly the case in pathology, where national patient safety alerts addressed to the entire health service workforce would be excessive. As a partial solution to this the National Patient Safety Agency has established an internet-based mailing list for the discussion of patient safety issues, which is open to any relevant healthcare staff. [8] This has provided interesting discussions of pathology-specific patient safety topics, often prompted by data from the NRLS. Its use however, is sporadic. More work needs to be done in developing mechanisms to extract and disseminate lessons from the NPSA's data collection systems. References The National Patient Safety Agency homepage. http://www.npsa.nhs.uk/ NPSA incident reporting – the NRLS. http://www.npsa.nhs.uk/health/reporting NPSA online incident reporting – the 'eform'. http://www.npsa.nhs.uk/health/reporting/reportanincident NPSA Alerts and Advice. http://www.npsa.nhs.uk/health/alerts NPSA initiative on patient identification. http://www.npsa.nhs.uk/site/media/documents/1440_Safer_Patient_Identification_SPN.pdf NPSA Incident Decision Tree. http://www.npsa.nhs.uk/health/resources/incident_decision_tree NPSA Root Cause Analysis training. http://www.npsa.nhs.uk/health/resources/root_cause_analysis 'Safer Pathology'; an NPSA internet mailing list. http://www.npsa.nhs.uk/health/resources/elists