Why should health care organisations connect to the NRLS?

1. Why should health care organisations connect to the NRLS? • Incidents which appear isolated and infrequent to an organisation, may not be on a national scale • Lessons can be learned • NHS Organisations with similar issues will be ‘matched’ so that they can be tackled collaboratively • Bounceback / feedback of relevant information • Data quality issues can be highlighted and dealt with via support from PSM

2. Components of the Campaign • NRLS • to patient safety • Aims to promote a clear and consistent approach • NHS organisations can use it as a reference guide • It will provide a framework for local organisations to develop or review their internal policies, processes and practices regarding patient safety. • Being open with patients

6. Safety Solutions Use of Hip Protectors to Prevent Fractured Neck of Femur in Acute Care Setting Identification of Visually Impaired Patients by use of stickers on Hospital and GP Records Safe Medication Practice for Children Staff training in the resuscitation of laryngectomy patients • Creating A Safer Environment on Acute Psychiatric Wards Reducing the Risk of Methotrexate Dosage Error Bowel care management for people with established spinal cord lesions in NHS organisations Determining the role of supervised consumption of Methadone in the reduction of accidental overdose Design for Patient Safety Burns/scalds arising from hot water in baths/pipes Clean your Hands Naloxone Provision by Ambulance Trusts • The restraint of older people Clinician Identifier Stamp • The identification and management of swallowing difficulties Infusion Devices Use of Non-Latex Products in the Care of Latex Sensitive Patients Wrong Site Surgery • Incorrect matching of patient with aspects of care Standardising the Crash Call Number

7. FUTURE

8. Other data sources Other data sources Secondary Uses NRLS WWW NHSnet NHS Care Record Service Model NCR LSP

9. Drivers for HL7 Compliance • Develop an HL7 compliant messaging model that accurately captures patient safety incident information. Complement this information with other data needed for aggregated analysis • Embed patient safety decision support systems (e.g. guidance, alerts) into HL7 compliant message flows. (e.g. CREDO)

10. Planned development for 2004 / 2005 • NHS Care Record System (NCRS) • HL7 messaging standard • SNOMED CT • ISB operational standard • Scope RCA reporting within the NRLS • Develop public / patient reporting • Extend to • Private sector • Prisons • Continue identifying options for working with other NHS organisations • WHO collaboration / international taxonomy of PSIs

11. Individual Case Safety Reporting

12. ICSR • Well suited for your current requirements • NPSA acknowledges that message development has to be iterative and user-driven • Recognises the huge amount of collective effort that has already gone into the ICSR • The NPSA wants to actively engage with PSSIG and assist in message development

13. NPSA Requirements • Model should facilitate incident reporting • Extend breadth of PSI categories • Omissions / commission • Facilitate use by confidential and anonymous reporting systems • Reflect PSI’s may occur to a group of patients or no-one at all

14. Requirements - Bounceback Thank you for submitting your incident report related to infection control. You may be interested to look at the work the NPSA has been doing in this area by clicking on the link below: You may also be interested to look at content on the following sites: NELH: Cochrane Library: http://www.npsa.nhs.uk/handhygiene http://www.nelh.nhs.uk/content/infectionctrl http://www.clib.ac.uk/cleanhands

15. Requirements - Feedback (Specific) • Trust: Royal Devon and Exeter • Top 5 incident types: • ……… etc. • Relevant actions taken nationally on these: • ……. • ……. etc. • Top 5 clusters detected: • Neo-natal unit and hypothermia • Burn and cup of tea between 3pm and 5pm • ……… etc.

16. Peer group average National average Requirements - Feedback (Contextualised) Trust: Royal Devon and Exeter Frequency A&E Dentistry Virology Genetics Obstetrics Specialty

17. Service area Incident location PSI date / time Country Incident category Underlying causes Contributory factors Actions Planned or taken Preventative Minimised harm Prevented PSI Age Paediatric ward Sex Ethnic category Impairment / disability Specialty MHCPA Harm Yes / No Degree Effect Staff type / status / role Information Requirements

18. Stage Medicine incident type Other contributory factors Approved (drug) name Proprietary (trade) name Form Dose and strength Route BNF classification Administration Intended drug Manufacturer Batch number Manufactured special? Registered EU importer Re-labelled for UK market Clinical trial Information Requirements - Medication

19. Type Current location Product name Model Catalogue number Serial number Manufacturer Supplier Batch number Expiry date Manufacture date Information Requirements - Devices

20. Wish List • Common definition for patient safety / PSI • Key requirements • Stakeholders • Specialism • Level of involvement • Other relevant HL7 messages • Synergistic action plan

21. chris.foye@npsa.nhs.uk