Socialist Health Association Promoting Health through Socialism

NPSA’s role in complaints

Peter Mansell April 2007

Purpose of the NPSA:

Special health authority with mandate to:

implement a national reporting system for patient safety incidents
collect and appraise information to promote patient safety
provide advice and guidance and monitor its effectiveness
promote research which contributes to patient safety
report and advise Ministers on matters affecting patient safety

Understanding the context of complaints:

Vision for NPSA Creating a Safer NHS:

Blame the reporter	Praise the reporter
Keep quiet	Open and Learning Environment
Safety is an ‘Add on’	Integration into care processes, education, R&D Programmes and Performance Assessment
Professional and Organisational Silos	National and International Partnerships Team Work, Local Quality Networks Patient and public involvement
Crisis	Clear Management systems
	Agreed work programmes for high impact,

Understanding the nature of error and harm

The National Reporting and Learning System (NRLS):

Confidential reporting database
Incidents are reported electronically
99% come from Local Risk Management Systems
Analysis of data at national level to
- identify trends and patterns
- provide feedback for local action
- inform NPSA work programmes

Care setting

Care setting	No.	%
Acute / general hospital	839,974	71.6
Mental health service	164,810	14.1
Community nursing, medical and therapy service (incl. community hospital)	116,633	9.9
Learning disabilities service	37,663	3.2
General practice	4,916	0.4
Ambulance service	4,160	0.4
Community pharmacy	3,943	0.3
Community and general dental service	353	0.0
Community optometry / optician service	13	0.0
Total	1,172,465	100.0

Source: reports to the NRLS up to Dec 2006

Degree of harm to patients

Degree of harm	No.	%
No harm	798,221	68.0
Low	295,562	25.2
Moderate	64,647	5.5
Severe	10,827	0.9
Death	4,588	0.4
Total	1,173,845	100.0

Seeing the whole picture

NPSA must use all available data sources to inform safety

Administrative data
Clinical incident reports
Medical records
Active surveillance or observation
Surveys - patients, staff
Complaints data

Learning from the NRLS and the PSO

Thematic reports
Bulletin
Trust feedback reports

Patient Safety Observatory reports

Patient Safety Bulletin

For example: Routine infusion of fluids

Single report of fatal incident following inappropriately prescribed fluids
Few reports related to this – not a well recognised risk?

Comparative feedback reports:

Ad hoc analysis:

Requests from NHS clinicians and risk managers, and relating to current NPSA projects
Use of categorical data supplemented by text searching tool

Examples during one week:

Chest x-ray for work on failure to review x-ray results
Clinical oncology/bone marrow
Learning disabilities choking incidents
Surgical incidents relating to policies and protocols
Maternity beds (elliot and lic types)
Non-medication prescriptions
Home oxygen therapy
Collapsible curtain rails

Systematic review of incidents

Richness of NRLS data in free text descriptions review from clinical perspective adds value
Huge volumes of data – sampling by specialty and incident type
Tools to support robust and consistent review of data supported by guidance and decision tree for follow-up action

eg: Operating list incidents

Under-reporting (and bias)

From case note review studies, estimated that LRMS capture 11-17% of patient safety incidents
Does under-reporting matter?
Alternative reporting routes - bias

Conclusion

Complaints data is one useful source of data to be used for safety improvement but because people respond to complaints in a variety of ways including being defensive and or not fully disclosing information other multiple sources are needed.
This provides a better more holistic picture of patient safety than any one data set could do so.

Kevin died. Kevin should not have died. We mourn for Kevin. ….. The tragic outcome in relation to Kevin cannot be changed. But can that outcome be a catalyst for change in the reformed health service?

By examining Kevin’s patient journey there can be real learning and real improvement at all points of patient contact. Perhaps Kevin’s destiny was to highlight for us the deficiencies and the challenge for us is to learn from his experience and to ensure that healthcare is safer for future patients.”

(A patient’s mother)

last updated 22/05/07