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)