Conference report: patient safety starts here

A patient safety congress sponsored by Microsoft received a surprise visit from Prime Minister Gordon Brown; and heard the case for new safety systems in the NHS, underpinned by information and supported by IT. Lyn Whitfield reports. 

The National Programme for IT in the NHS is to be given a new focus on patient safety following the publication of Lord Ara Darzi’s review of the health service this summer.

NHS chief executive David Nicholson told a patient safety congress in London that the programme would be “repositioned” in line with the outcome of the review, which is expected to call for a new focus on quality and safety.

“One of my responsibilities is NHS Connecting for Health [the agency that runs NPfIT],” Mr Nicholson told the congress organised by Nursing Times and the Health Service Journal, and sponsored by Microsoft and NHS agencies. " “I was once told that the most dangerous instrument in the hand of a clinician is a pen...opportunities exist for technology to provide us with some answers; so we need to reposition NHS CFH as a real benefit for patient safety.”

“We have had some issues with it over the past six years, but now we need to do two things. The first is to devolve it to the frontline. The second is [to realise that] NHS CFH is potentially the greatest step forward in patient safety we can have.”

Mr Nicholson argued that the electronic record and prescription pilots being run by NHS CFH were already showing that IT could improve patient safety by reducing errors due to missing, incorrect or simply illegible information.

“I was once told that the most dangerous instrument in the hand of a clinician is a pen,” he went on. “Opportunities exist for technology to provide us with some answers; so we need to reposition NHS CFH as a real benefit for patient safety.”

Patient safety matters

Delegates to the congress at London’s Excel centre heard two main messages from its keynote speakers. First, that the NHS will be expected to pay more attention to quality and safety in the future than it may have done in the past.

And second, that a body of international evidence now exists about the scale of harm caused by health services and what works and what does not work in trying to reduce it.

The first point was underlined by a surprise visit from Prime Minister Gordon Brown, who told delegates that meeting rising patient expectations – including expectations of safety – would be crucial to the future of the health service.

“People are living longer and they will want treatments that may not have been available in the past,” he said. “They will also want to know that the NHS is not just there when they need it, but that it will be personalised to them, and that it will deal with problems like the ones that we are talking about today.”

It was also underlined by Mr Nicholson, who argued that the NHS had been on a “journey” since New Labour came to power a decade ago, that had started by increasing health service capacity and then focused on the technicalities of reform.

“The third bit – the bit we are doing now – is saying ‘how do we use that capacity and that reform to change the service we have got’... with a clear focus on why we are here,” he said. " “He reverted to standard operating procedure. He didn’t say ‘I’m a pilot, let’s get this jalopy down’.”

“One of the things that Ara Darzi will be clear about is that we need to make quality the foundation of the NHS,” he added, saying that this would not be done through more centralised targets, but through devolution and locally backed campaigns.

International lessons

Having established the case for patient safety, speakers emphasised that health systems everywhere struggle to deliver it. Several cited To Err is Human, a landmark US study that estimated that between 40,000 and 100,000 people die every year as a result of adverse medical events.

This 1999 study noted that this would make adverse medical events the third most common cause of death in the US. Similar studies in other countries have come to similar conclusions; while estimating that up to three quarters of incidents may be preventable.

Speakers also emphasised that healthcare associated infections, medication errors, accidents and other adverse incidents cannot be reduced by exhorting staff to do better, or blaming them when things go wrong.

This is an idea associated with James Reason, who wrote another key study, Human Error, in the early 1990s. This argued that error is inevitable, so systems must be designed to prevent and spot it whenever possible. And it has been developed by Don Berwick, who runs the Institute for Healthcare Improvement in Boston.

He told the congress that “unsophisticated” leaders could actually perpetuate high rates of adverse incidents by exhorting staff to do better in error prone systems. This, he said, simply forced people to adopt “defensive behaviours” when things went wrong.

“Within a team, the leader’s role is to encourage a focus on identifying hazards and to encourage change to remedy them,” he said. “We have to stare this problem in the face; but we also need ideas about how to change systems to get the outcomes we want - and we need to execute those ideas.” "NPfIT is not an IT programme, but a patient safety and a clinical governance programme."

Airline-style safety

Similar themes have been explored by the chief medical officer, Professor Liam Donaldson. He produced the Organisation with a Memory report in 2000 that argued the NHS had much to learn from other safety critical industries – such as the airline industry.

Sir Liam told the conference that clinicians sometimes resisted the introduction of “industrial” processes to the NHS out of concern that this would undermine their professionalism. However, he contrasted this concern with the attitude of pilots, who work to standard operating procedures and frequently have their reactions tested in simulators.

“Some of you may remember a recent incident at Heathrow, in which a plane was landed safely by a pilot called John Coward,” he told the congress. “I spoke to him recently, and he said that when it happened, ‘it was just like being in a simulator.’ He reverted to standard operating procedure. He didn’t say ‘I’m a pilot, let’s get this jalopy down’.”

Campaigning by numbers

The IHI has launched two major campaigns – the 100,000 Lives campaign and the 5 Million Lives campaign - to encourage healthcare organisations in the US to adopt simple packages of measures to reduce the incidence of particular types of adverse medical incident. "The standard chosen – IEC 61508 – requires developers and vendors to assess hazards and build a safety case for their products that also covers issues that might arise from their implementation and use."

These ideas lie at the heart of similar initiatives underway in Scotland and Wales and will form the basis of a campaign to be run in England by the National Institute for Innovation and Improvement. However, they did not go down well with congress chair John Humphries.

He claimed a patient safety “crisis” had been brought about by a managerial focus on finances and government targets. This brought a robust response from health minister Ann Keen, who said there had never been a “golden age” of patient safety; and some targets focused on quality issues.

Frank Hamill, clinical audit and assurance manager at North Bristol trust, told an information and technology stream session away from the main conference hall that the ideas in the Welsh 1,000 Lives campaign worked.

However, he said they crucially depended on information about incident rates and how well staff were complying with standard processes – and on a willingness to keep going if the data showed that both were worse than clinical teams assumed.

Mr Hamill said it was vital to agree definitions of what was to be measured up front, to make sure front-line data collectors understood them and could sustain data collection, to analyse data effectively – using run charts, which show change over time – and to provide feedback.

“Staff will see the benefits very quickly, and that reinforces the fact that process compliance is important,” he said. “Boards will also become more engaged, because they can see impacts across departments.”

The National Programme for patient safety

Maureen Baker, national clinical lead for safety at NHS CFH, told another information and technology stream session that it was committed to supporting such developments.

“When NPfIT was launched, its strapline was ‘modernising the NHS’, which was great, because we all want to be modern and up with the times,” she said. “However, you have to ask what we are modernising for; and, for me, it was always about developing systems that would help clinicians to practice more safely.

“Now, Gordon Hextall [chief operating officer at NPfIT] often says that NPfIT is not an IT programme, but a patient safety and a clinical governance programme. And post [Lord Darzi’s] review, it will be positioned explicitly as a patient safety programme.”

Dr Baker also outlined how NHS CFH had taken a “safety approach” to new software. She said other “safety critical” industries took this approach, which meant being able to say “this is how we do safety around here” – or these are the standards we work to and this is the documentation that shows how we implement them.

She said she had worked with engineers – “the sort of people who go and put missile systems into things like tanks” – to identify a standard that applied to the process of developing software.

The standard chosen – IEC 61508 – requires developers and vendors to assess hazards and build a safety case for their products that also covers issues that might arise from their implementation and use. International bodies are now working on a standard specifically for healthcare IT that will adopt similar principles.

Ms Baker outlined other safety initiatives taken by NHS CFH, including a system for reporting IT safety incidents and making them safe, a programme to train clinicians in the safety aspects of IT, and programmes to encourage blood and asset tracking using bar-codes and RFID.

Technology at work

In the technology stream and at the exhibition linked to the congress, Microsoft partner Safe Surgery showed how RFID tags can be embedded in wrist-bands and used to link patients to notes and to track them through surgical procedures in a system developed and deployed by Birmingham Heartlands Hospital.

Meanwhile, NHS CFH has also been working closely with Microsoft on its Common User Interface programme. This has been looking for ways to make it easier for the NHS to maintain infrastructure, deploy new technology, and make systems safer since 2004.

One of its strands of work has been to develop design guidance on how things like demographic and medication information should be displayed in NHS systems and to produce components that developers can use in their own applications.

The more systematic display of names, dates, medicine names and other items should improve patient safety by preventing confusion among staff who have to use many different applications. Programme head Andrew Kirby took a new demonstrator to the congress showing how this work might be used in systems in the future.

Further Reading

- View the latest CUI programme demonstrator 

- Find out more about the Common User Interface Programme (CUI)