Patient Safety – agencies of note

In Evidence-Based Medicine on March 26, 2010 by africker Tagged: ,

Recently pulled together details of a range of agencies involved in Patient Safety work.  Present here for peoples interest.  The patient safety agenda is another place where information professionals can definitely provide valuable support.

National Patient Safety Agency 

They say: We lead and contribute to improved, safe patient care by informing, supporting and influencing organisations and people working in the health sector.

 Products include:  Patient Safety Alerts, “Seven Steps to Patient Safety”, guidance on best practice and toolkits. 

 Sample project:  Matching Michigan

This is a patient safety project based on a model developed in the United States which, over 18 months, saved around 1,500 patient lives.  It took place at ICUs in Michigan and introduced measures that reduced central venous catheter (CVC) associated bloodstream infections.

 Patient Safety First Campaign

They say: Led by the service for the service, Patient Safety First has at its heart a vision of an NHS with no avoidable death and no avoidable harm.

Products include:  Generating involvement, interventions, implementation support tools, training / events

Sample project: High Risk Meds

This intervention programme addresses the four medicines responsible for the most incidents of severe harm (based on NPSA data).  Materials outline how to implement 6 core evidence based interventions and a further 9 additional measures. 

Linked bodies in other UK Home Nations

The Health Foundation

They say: The Health Foundation is an independent, charitable foundation working as a catalyst to improve the quality of healthcare in the UK and beyond.

We identify evidence about issues and solutions through research, commission improvement programmes to test ideas and build skills, promote our learning to policy makers and people in healthcare, and develop people to lead quality into the future. 

Products include:  Leadership development, patient safety programmes, comparative studies, clinician engagement

Sample project: Safer Clinical Systems

The programme aims to develop a set of strategies to improve patient safety building on those developed through the Safer Patients Initiative and other patient safety programmes. By testing and measuring their impact we will seek to fill the current gap in the evidence base.

We’ll develop a set of standard shared measures to demonstrate impact against. We’ll then share this knowledge and learning with the wider NHS.  Currently at proof of concept stage.

NHS Institute for Innovation and Improvement

They say : The NHS Institute for Innovation and Improvement supports the NHS to transform healthcare for patients and the public by rapidly developing and spreading new ways of working, new technology and world class leadership.

Products include : Productive programmes, Leading improvement training, trigger tools, huam factors work.

Sample project: BaSIS: Building Safety Improvement Skills

BaSIS is a package of interventions designed to enable junior doctors to become a force for safe practice by:

  • Giving them the skills they need to be safe
  • Empowering them to make improvements within their Trust

 WHO Patient Safety 

They say: The programme, WHO Patient Safety, aims to coordinate, disseminate and accelerate improvements in patient safety worldwide. It also provides a vehicle for international collaboration and action between WHO Member States, WHO’s Secretariat, technical experts, and consumers, as well as professionals and industry groups. Each year, WHO Patient Safety delivers a number of programmes covering systemic and technical aspects to improve patient safety around the world.

Products include:  Research, Learning from error, patient safety curriculum for medical students,  5 moments for hand hygiene, patient safety checklists.

Sample project: Surgical Safety Checklist

The WHO Safe Surgery Saves Lives Checklist was created by an international group of experts gathered by the WHO with the goal of improving the safety of patients undergoing surgical procedures around the globe. Input from anesthesiologists, operating theatre nurses, surgeons, patients and other professionals was used in the development of this tool. Both small and large scale clinical testing of the checklist has been performed culminating in a multi-site pilot study with results published in the New England Journal of Medicine in January 2009

In sites that ranged from small district hospitals to large medical centers in diverse geographical settings, the use of a 19-item checklist was demonstrated to reduce the complications and mortality associated with a variety of surgical procedures by greater than 30 percent. The checklist has been designed to be simple to use and applicable in many settings. It is currently in active use in operating rooms around the world.

See alsoWHO Collaborating Centre for Patient Safety Solutions

Department of Health – Patient Safety

They say:  Ensuring the safety of everyone who comes into contact with health services is one of the most important challenges facing health care today.

Products include:  Good range of background documentation, clinical governance, antibiotic resistance, health care standards

Sample ProjectCleanyourhands

The Cleanyourhands campaign consists of posters, raising awareness guidance, promotion of the right hand hygiene for the right condition.

From April 2008, the campaign has been rolled out to NHS primary care, mental health, ambulance and care trusts in England and the one remaining trust not included in Wales (the ambulance service). Over 90% of eligible organisations have signed up for the campaign so far.

Independent evaluation of the campaign has concluded that it has been successful in changing the hand hygiene behaviour of healthcare staff in acute trusts. There has been a significant increase in the amount of alcohol handrub and soap being used in the NHS since the introduction of the campaign and the campaign is still considered a priority in approximately 80% of trusts.  Intensive auditing has demonstrated significant improvements in hand hygiene by clinical staff in hospitals.

Patient Safety Board

They say: Patient safety is an issue which concerns all those who care for patients and lies at the heart of medical practice. All surgeons have a primary responsibility to participate in established procedures and to develop new measures to improve patient safety: the Royal College of Surgeons of Edinburgh Patient Safety Committee is committed to improving standards through education and training and by supporting research into human factors which may prevent or mitigate patient harm.

Products include: Safer operative surgery, Non-Technical Skills (NOTSS), updates / publications

Sample Project:  NOTTS Masterclass

NOTSS is a behavioural marker system for surgeons. It allows consultant (attending) surgeons to give feedback to colleagues and trainees on non-technical aspects of performance such as situation awareness, decision making, teamwork, and leadership. It was designed to be used in the intraoperative environment (i.e. in the operating theatre) to guide observation, rating and feedback during clinical encounters.

Institute for Healthcare Improvement

They say : The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world.  Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action.

Products Include:  Improvement Map, campaigns (eg 5 Million Lives), Open School (patient safety competencies)

Sample projectSafer Patients Network

Working with the Health Foundation.  Will sustain and strengthen the impact of the Safer Patients Initiative. Create opportunities to test and develop new approaches to patient safety – others within the network and the wider system can then take these forward. These sites will then offer coaching, mentoring and support in improving patient safety to the wider health system

Agency for Healthcare Research and Quality (US Dept Health & Human Services)

They say: The Agency for Healthcare Research and Quality’s (AHRQ) mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Information from AHRQ’s research helps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research.

Products include: National quality measures clearing house, patient safety tools, analysis of medical errors, quality indicators

Sample projectPatient Safety Network

Web-based resource featuring the latest news and essential resources on patient safety. The site offers weekly updates of patient safety literature, news, tools, and meetings (“What’s New”), and a vast set of carefully annotated links to important research and other information on patient safety (“The Collection”). Supported by a robust patient safety taxonomy and web architecture, AHRQ PSNet provides powerful searching and browsing capability, as well as the ability for diverse users to customize the site around their interests (My PSNet).

Joint Commission

They say:  The Joint Commission is committed to improving health care safety. This commitment is inherent in its mission to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. At its heart, accreditation is a risk-reduction activity; compliance with standards is intended to reduce the risk of adverse outcomes.

Products include:  National patient safety goals, infection control, Speak up, universal protocol

Sample project:  “Do Not Use” list

A list of abbreviations that must not be used in patient notes due to potential for confusion.

Patient Safety Research Groups

 Various groups in UK Universities – non exhaustive list.

Imperial Centre for Patient Safety and Service Quality (CPSSQ)

Includes very useful database of patient safety projects

Lancaster Patient Safety Research Unit 

King’s Patient Safety & Service Quality Research

Patient Safety Research Group University of Aberdeen

Australian Commission on Safety & Quality in Healthcare

They say:  The Commission was established by the Australian, State and Territory Governments to develop a national strategic framework and associated work program that will guide its efforts in improving safety and quality across the health care system in Australia.

Products include:  Clinical handover, medication safety, information strategy, knowledge portal, patient identification

Sample project:  Recognising and Responding to Clinical Deterioration

The main initiatives in this program to support work at a national level include the development of:

  1. a nationally agreed consensus statement regarding the essential elements for recognising and responding to clinical deterioration.
  2. An implementation guide to support the consensus statement and provide information about how the elements within it can be put into practice for all patients across all acute settings.
  3. an evidence-based adult general observation chart that will incorporate features to support the identification of patients who are deteriorating, and prompt action to properly manage these patients.

One Response to “Patient Safety – agencies of note”

  1. […] This post was mentioned on Twitter by DougSalz. DougSalz said: Patient Safety – agencies of note: #ptsaftey #ebm […]

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