Patient Safety

Patient Safety Tony Newman-Sanders National Clinical Advisor NHS CFH London Cluster

Structure and Documentation • NPSA only involved once Trusts connected to spine. • Best practice documentation • Most issues local /Trust/entity responsibility. • Role of LSPs • Safety documentation patchy

Old issues and New opportunities • Old issues • IRMER • Incorrect patient ID or Study ID • Notification and action on reports • New opportunities • Improved access to reports, PDA bedside telephony etc • Integrating other data eg text books, drug data • CAD, • Comprehensive error review, double reporting etc

Ionising Radiation • Several RIS-PACS issues identified at BLT • Nuclear Medicine • Vetting, approving, justifying • Report data • Implications of rapid roll out of CR • Specific equipment issues • Radiographer behaviour

Patient ID • Intrinsically much safer than film • Significant possibilities for error • Unique Patient ID • NHS number • PAS number plus prefix • RIS (PACS) generated number plus prefix • What is easily accessible to clinicians? • Webbrowser design.

Notification and acting on results • Significant proportion of cases of serious harm or death identified by NPSA • NCRP tasked with identifying where the solutions lie • PAS • RIS • PACS

Interdependencies • Structure of archiving • Connectivity within cluster • Legal liability issues • Short term IG vs strategic robustness. • Responsibility and reporting structure

New opportunities • Improved access to reports, PDA bedside telephony etc • Integrating other data eg text books, drug data ????NICE • CAD, • Comprehensive error review, double reporting etc • Any others?

Patient Safety

Patient Safety

Presentation Transcript

Patient Safety

Patient safety

Patient Safety

Patient Safety:

Patient Safety

PATIENT SAFETY

Patient Safety

Patient Safety

Patient Safety

Patient Safety

Patient Safety and Patient Identification

Patient Safety

Patient Safety

patient safety

Patient safety