Keeping harm at bay

Unfortunately we cannot assume that patients will not come to harm in hospitals. Despite the best intentions of those who care for them, a disturbingly large number of patients experience some harm whilst in our hospitals. Each and every person working within a hospital is responsible for the safety of the patients being treated. Accountability does not sit only with the front-line clinical staff but is everyone’s responsibility, from Board members, porters, reception staff and, of course, managers.
    
This article outlines the aim of the Patient Safety First Campaign for England, which is to ensure that patient safety is the highest priority for all on a day-to-day basis, across all levels of the NHS with no avoidable death and no avoidable harm in our health services.

We are all affected
When an incident occurs, it is not only the patient and their families that suffer; the clinical staff involved in the incident can be left scarred by a feeling of guilt and sometimes despair that the system did not help them enough. All people make mistakes and we need to recognise that. It is all too easy to blame an individual for an error but in the vast majority of cases it is the systems and processes in place that lead to mistakes resulting in harm to patients.
    
This is where the role of managers and leaders comes in. We must create an environment where the processes in place support staff to do the right thing and protect both patients and staff from the wrong thing happening. And when it does, it is the leadership that must create a just culture where individuals feel it is safe to own up to error and to learn from such events.
    
In order to effectively reduce the number of adverse events that occur in the NHS, we all need to face the fact that the culture within the service has to change. It is not enough to react to incidents; the Patient Safety First Campaign for England is about actively looking for examples of harm. Doing this effectively requires leadership from the top and real partnerships between clinicians and managers to negotiate an organisation’s systems, to find the data that will support improvement.

The current situation
The term ‘Patient Safety’ is on everyone’s lips and not least at the NHS Confederation Conference in June this year. Launching the Campaign at the conference to an audience of clinicians and managers, we demonstrated why there is a need to change attitudes within the NHS and why staff need to be empowered to allow this change to happen. This campaign is innovative – it is not target-driven or directed from the top down. It has been developed by the service, for the service, and will give NHS staff access to proven best-practice methods in a simple, straightforward and supportive way.  
    
The NHS is a massive organisation. Every day more than a million people are treated successfully, but in complex healthcare systems things will and do go wrong no matter how professional and dedicated the staff. Estimates suggest that one in ten patients admitted to hospital experience an incident or adverse event. that puts their safety at risk and about half of these could have been prevented.
    
This is an international issue and it has been recognised that there is much avoidable harm happening in hospitals across the world. Campaigns across several countries have shown that there are methods that if employed correctly, will successfully reduce the number of these incidents. The English campaign is part of an international movement to make hospitals safer. Similar campaigns in the US, Canada, Scotland, Wales and Denmark are saving lives.  
    
Our campaign began on the back of the Chief Medical Officer’s 2006 report Safety First, which suggested centrally-led initiatives were not making sufficient inroads into improving patient safety. We wanted to find interventions that work across care settings and mobilise everyone, especially leaders and managers.

The Campaign in action
The Campaign is initially focused on the application of five interventions, including four clinical interventions. An intervention is simply a set (or ‘bundle’) of actions that, if introduced together into a patient’s care management, will significantly change the processes and outcomes of their care.
    
The fifth and most important intervention is Leadership for Safety and we believe that this is so crucial to the success of the campaign that we are insisting that all organisations sign up to it. The purpose of this intervention is to help signed-up Trusts ensure a leadership culture, starting at Board level, which promotes quality and patient safety and provides an environment where continuous improvement in harm reduction becomes routine throughout the organisation. Without strong leadership, the positive changes needed cannot be made.
    
As managers, you will often see the affects of adverse events and will agree that patient safety has got to become the priority across all sectors of the NHS. No one is suggesting that steps are not taken currently to secure patients’ safety but we are often distracted into thinking that national targets or financial balance are more important since these aspects get more leadership attention at all levels of the NHS. A recent HSJ survey reinforced the view that patient safety was NOT seen as the highest priority;  - this Campaign seeks to make it so and the leadership intervention, alongside support from you, will make this happen.

The clinical interventions
The four clinical interventions have been chosen because they relate to known major sources of harm. The initial focus is on Acute Trusts since there is already published evidence from other countries and UK organisations on how to improve practice by implementing four clinical interventions. In addition, many Trusts are already doing work in these areas, and through this campaign they will be supported and aided in their efforts, while being encouraged to share their success with other Trusts.
    
The campaign has already proven incredibly popular beyond Acute Trusts and we are keen for Primary Care Trusts, Mental Health Trusts and Ambulance Trusts to sign up. They can issue the pledge to staff about patient safety being their highest priority; they can take on the leadership intervention and they can adapt some of the acute interventions. We also aim to influence other key organisations such as royal colleges, professional organisations and regulatory bodies to engage them in this life saving cause.
    
The clinical interventions initially being focused on are:

• Reduction of harm to deteriorating patients in acute care - AIM: Reduce in-hospital cardiac arrest and mortality rate through earlier recognition and treatment of the deteriorating patient
• Critical care bundles (central line and ventilator care) - AIM: Improve the care of patients receiving critical care through the reliable application of care bundles 
• Perioperative care, including prevention of surgical site infection and World Health Organisation’s Safe Surgery Checklist - AIM: Improve care for adult patients undergoing elective surgical procedures in the hospital setting
• Reduction of harm from high-risk medications (this includes anticoagulants, narcotics, insulin & sedatives) - AIM: To prevent harm from high-risk medications.

Who’s behind it?
The campaign is taking what has been learnt internationally and applying it in England, working alongside a core team of experienced professionals, who all have experience of patient safety initiatives within their own NHS organisations.
    
The core team is led by Campaign Director Stephen Ramsden, Chief Executive of Luton and Dunstable Foundation Trust, and made up of dedicated clinicians and managers from across England, each passionate about improving patient safety in their own field and on hand to help you put the campaign into action.
    
In my own hospital, we have seen the positive impact that these interventions can produce. As part of the Safer Patients Initiative we have reduced our Hospital Standardised Mortality by 15 per cent and seen a 70 per cent reduction in MRSA and C. Difficile infections. In addition, the reductions in infections in ITU have helped us to reduce our patients’ length of stay in this unit, as well as elsewhere in the hospital. This means we can offer this facility to more patients who need it.
    
To do this we have tried to lead from the front with executives carrying out walk-rounds to all areas of the hospital to discuss with staff their concerns about patient safety. By seeing how patient safety is put into practice first hand, we know how best to support the clinical staff and they know that you are on their side.

What it means in practice
We know that creating a culture that really addresses avoidable harm means that there should be visible signs that patient safety is taken seriously. For instance, it should be the first item on every department meeting agenda.
    
Resources need to be allocated to support real improvement, for instance funding for a dedicated patient safety manager or freeing up a clinician’s time to audit case notes properly. An organisation that isn’t prepared to invest in patient safety can’t truly say it’s the highest priority.
    
Leaders, whoever they are, need to set the right example and proactively look for instances of harm, like auditing case notes on a regular basis and analysing mortality rates.
    
The crucial element is getting real buy-in to making patient safety your organisation’s top priority, more important than meeting performance targets. It’s a courageous board that will sign up to that.

How the Campaign supports you
The Campaign website www.patientsafetyfirst.nhs.uk not only provides you with access to methods proven to work, how-to guides for each intervention and measurement, but also information on the support provided at a local level to help you put them into practice. NHS staff gain peer-to-peer advice together with access to training for instance on the Global trigger Tool for Adverse Incident audit, taking place regionally. These workshops are designed to provide an overview of measurement and training on how to complete a review and are aimed at all those who will be undertaking the case notes review.
    
Also available are a series of tele-web conferences via WebEx where you can receive advice and support from the core team. Practical Insight Open Days are also being held around the country.  

The Campaign needs you
We are asking you to urge your Trust to sign up to at least one more intervention on top of the Leadership pledge through the registration process online. We urge individuals also to join so that you can offer your experience and support and share advice with others carrying out the same improvements in hospitals up and down the UK. With the Campaign live for two years, the support networks will develop over time to reflect the successes and challenges faced by those on the front line, with plans to increase the number of interventions to make a difference across even more sections of the NHS.

Working alongside other initiatives
As you are aware, there is amazing work already underway in hospitals, including the Health Foundation Campaign to support Safer Patient Initiatives Trusts across the UK, and the NHS Institute Leading Improvement in Patient Safety. This programme is working with 23 Acute Trust, and aims to help NHS Trusts develop organisational plans for patient safety improvements and to build teams responsible for driving improvement across their organisation. The Patient Safety First Campaign for England is sponsored by the Health Foundation and the NHS Institute for Innovation and Improvement, as well as the National Patient Safety Agency and is working with existing networks/organisations and also creating some new networks to offer vital support to local organisations in the implementation task.
    
The key difference with the Patient Safety First Campaign is that it is not target driven. Rather it seeks to shift hearts and minds and move people to want to make patient safety their highest priority in their day-to-day work. Patient safety will always be about the number of lives saved and the amount of harm avoided, but this campaign will help facilitate the change needed in the NHS – looking out not up.  

The way forward
We’ll be presenting the campaign at events across the UK right up until the end of the year in order to reach as many NHS staff as possible. We want all Trusts to sign up and we need your help to make this happen. The campaign is calling for more Chief Executives and individuals to pledge their support, to sign up, register online and actively support us.
    
Working together, we are looking to change the culture within the NHS to one that puts the safety of patients as the highest priority. We need to stop accepting the unacceptable. Join the campaign to help save lives and support each other in making our aim a reality.

Dr Peter Cavanagh is member of the core team for the Patient Safety First Campaign. He has recently moved from his position as Medical Director of Taunton and Somerset NHS Acute Trust, where he was based for the last nine years0. This tenure concluded with an 18-month period as Acting CEO. Peter is now a Consultant Adviser on Patient Safety to Somerset Primary Care Trust, as well as Medical Adviser to NHS Southwest.

For more information
For up-to-date information, log onto the campaign website at www.patientsafetyfirst.nhs.uk.
For more information on the interventions and to find out how to sign up to the campaign, contact info@patientsafetyfirst.nhs.uk.