Patient Safety

In NHS North East Essex we are focussing upon raising awareness of the importance of using the NHS Number. Between June 2006 and the end of August 2008, the National Patient Safety Agency received over 1,300 reports of incidents resulting from confusion and errors about patients’ identifying numbers. Many of these involved duplication in local numbering systems, for example, two patients having the same number, or one patient having more than one number. Although no deaths or instances of serious harm have been reported yet, concern remains at the significant risk to patient safety. Therefore from the 18th September 2009 all NHS organisations should ensure that the NHS Number is used as the primary patient identifier and have in place processes to ensure patients know and are encouraged to use their NHS Number. NHS staff can find further details at http://nww.eastern.nhs.uk/scripts/index.asp?pid=120694&id=120696

Rachel Hearn
Interim Head of Patient Safety
NHS North East Essex

The vast majority of NHS care is safe but mistakes do happen, sometimes with tragic consequences. We can only prevent these problems if we learn from what goes wrong.

The United Kingdom was one of the first countries to take a systematic approach to tackling patient safety. The Chief Medical Officer's report

An Organisation With a Memory concluded that if the NHS is to successfully learn from errors, four areas need to be addressed:

A unified mechanism for reporting and analysing incidents when things go wrong
A more open culture, where errors and failures can be reported and discussed openly and without fear of recrimination
Mechanisms for ensuring that where lessons are identified, the necessary changes are put in place to make the same error less likely in future
A much wider appreciation of the value of systematic approaches to preventing, analysing and learning from errors.

Recommendations from this report were accepted by the Government in Building a Safer NHS for Patients and the National Patient Safety Agency (NPSA) was established as a result.

NHS North East Essex approach

Our intention is to develop a co-ordinated, cohesive approach towards patient safety across NHS North East Essex which will promote positive outcomes.

A Patient Safety Group has been formed to implement all aspects of patient safety in primary care using the 7 Steps to Patient Safety. Monitoring of our achievements against the 7 steps is achieved through the NPSA monitoring tool which, in addition, measures our achievements against Standards for Better Health developmental standards for the safety domain 1.

A Patient Safety Implementation Strategy has been developed to work in harmony with the Being open about patient safety incidents (Adobe Acrobat - 146 Kb), Risk Management Strategy and Policy and the Health and Safety Policy.

The strategy sets out clear objectives for NHS North East Essex, many of which have been put into action already. For example:

We have many active patient safety champions from all disciplines who will be supporting awareness to and developments around patient safety incidents but we are always looking for more people from all walks of life to be our champions. (See right for contact details)
We are in the second year of running the Patient Safety Clinical Manager Development Programme, with the main focus being improving practice in relation to patient safety issues
Training has been provided for Root Cause Analysis (understanding the causes when things go wrong) and Being Open (telling people why things go wrong and being open about the facts). These processes are crucial to patient safety.
An organisation-wide awareness survey has been cascaded to all staff and will be re-audited in 2008.
Patient safety walkabouts - research has shown that regular walkabouts are a critical factor in developing a safer culture and improving patient safety. These visits are not about inspection or monitoring, but support, guidance and two-way feedback. They can take place at all levels talking to staff, identifying problems and issues, and working jointly towards a more open safety culture.
The Best Practice Bite Size newsletter which draws on local patient safety incidents and complaints and shows improvements that have been made to practice as a result
Patient Commissioning Forums where patients are actively involved in the commissioning of health services and can challenge health managers directly