Avoidable mistakes cost patient lives

Autumn headlines highlighted the catastrophic outcome of poor clinical governance within the Maidstone and Tunbridge Wells NHS Trust. A Health Commission Report1, published in October 2007, found C.difficile was the main cause of death of 90 patients. A total of 1,170 people were infected with C. difficile during their stay between April 2004 and September 2006. The Healthcare Commission said a "litany" of errors in infection control had caused the "avoidable tragedy".
    
Whilst resource and staffing pressures were identified as factors, blame was also placed on a lack of systems to support the delivery of healthcare services.

Policies – the foundation of best practice
The Healthcare Commission acknowledged that it is important for trusts to have up-to-date policies and procedures for infection control that are easily available to staff. However, in this case all but one of the 31 policies in the trust’s manual for infection control was several months past its review date. In addition, the trust acknowledged that its policy for handling outbreaks at the time was ‘not fit for purpose’. Unsurprising then that staff reported that they did not refer very often to policies either posted on the Intranet or in hard copy policy manuals.
    
That’s why more and more organisations are turning to automated software to reduce the problems associated with poor policy management. These solutions manage the whole policy lifecycle, from creation through to audit. Furthermore, as the administrative overhead of policy management becomes less onerous, an opportunity is created to ensure that policies fulfil their role of improving working procedures, ensuring patient safety and ultimately enhancing healthcare services.

Building a culture of compliance
According to leading policy management software vendor, NETconsent, pro-actively communicating best practice policies to NHS staff (including bank and agency staff), so that they clearly understand what is expected of them, can dramatically improve the culture of compliance. However, without gaining staff buy-in to policies and ensuring that management is prepared to enforce written standards, working practices on the ground may not be improved. NETconsent software has a complete audit trail of when policies are published, revised, seen and agreed to by staff, so that accurate management reports can be acted upon quickly. There is even a comprehension testing module, which is used to identify poorly written policies or a lack of policy understanding amongst staff.
    
It is naïve to think that all errors can be eliminated through better policy management. However, their frequency and impact on patient safety can certainly be improved. In 2005 almost one third of the 1,804 serious incidents resulting in death reported to The National Patient Safety Agency were considered avoidable. Such incidents typically involve multiple failures of procedure, which foster the conditions for a serious error to occur. So improving adherence to even a few core policies and working practices is likely to prevent or reduce the risk of harm to patients.
    
Gavin Cox, head of IT infrastructure at NHS Lanarkshire understands the importance of effective communication. “We regularly receive ‘Safety Action Notices’ from the Scottish Executive Health Division (SEHD)” he says, “and it is essential that the Trust communicates these to the relevant staff as simply and as quickly as possible to minimise patient risk. Moreover, the Trust needs to be sure that everyone has received these notices, providing proof if necessary. NETconsent simplifies this whole process and gives us greater confidence in our communication process.”

Restoring public confidence
Confidence in the national health system remains at an all time low. Patients and the public are demanding improved standards of healthcare. Consequently NHS hospitals and staff are being subjected to an ever increasing level of public scrutiny. Now more than ever, good clinical governance is paramount to ensure patient safety and quality of care. Improved standards of policy management have a critical part to play.
    
Robin Saunders, managing director of NETconsent says: “If NHS policies and procedures are to make a real difference to staff attitudes and clinical activities they must be better communicated, regularly reviewed and effectively enforced.” He added: “Our software gives our NHS customers greater confidence in their communication processes and ensures core policies can be updated and distributed as soon as new guidance is issued.”
    
With compensation claims likely to rise even higher, the NHS needs to get its house in order. The £579.3 million (damages and legal costs) paid out in connection with clinical negligence claims in 2006-07 undoubtedly could have been better spent on frontline healthcare services.

Reducing the risk 
To reduce the risk and the likelihood of avoidable errors have policies, which are:

• Clearly written to reflect legislation and published professional guidance
• Pro-actively distributed to all staff (including bank & agency)
• Understood by all staff
• Agreed to by all staff
• Workable in practice (i.e. the Board ensures adequate resources are available)
• Consistently enforced by senior practitioners and management
• Audited to ensure compliance
• Reviewed and updated regularly

Notes
1 Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust, October 2007

For more information
NETconsent Ltd
Tel: +44 (0)870 013 1600
Email: info@netconsent.com
Web: www.netconsent.com/health