Why should health care organisations connect to the NRLS?

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

• 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

Components of the CampaignComponents 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

• 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

The restraint of older people

Safe Medication Practice for Children

Determining the role of supervised consumption of Methadone in the reduction of accidental overdose

Creating A Safer Environment on Acute Psychiatric Wards

Burns/scalds arising from hot water in baths/pipes

Wrong Site Surgery Use of Non-Latex Products in the Care of

Latex Sensitive Patients

The identification and management of

swallowing difficulties

Incorrect matching of patient with aspects of care

Standardising the Crash Call Number

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

Design for Patient Safety

Reducing the Risk of Methotrexate Dosage

Error

Staff training in the resuscitation of

laryngectomy patients

Infusion Devices

Bowel care management for people with established spinal

cord lesions in NHS organisations

Clean your Hands

Naloxone Provision by Ambulance Trusts

Clinician Identifier Stamp

Safety SolutionsSafety Solutions

FUTUREFUTURE

NHS Care Record Service ModelNHS Care Record Service Model

Other data sources

NHSnet

WWWNRLS

NCR

Secondary Uses

Other data sources

LSP

Drivers for HL7 ComplianceDrivers 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)

• 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)

Planned development for 2004 / 2005Planned 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

• 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

Individual Case Safety ReportingIndividual Case Safety Reporting

ICSRICSR

• 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

• 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

NPSA RequirementsNPSA 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

• 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

Requirements - BouncebackRequirements - 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:

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

Requirements - Feedback (Specific)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.

• 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.

Requirements - Feedback (Contextualised)

Requirements - Feedback (Contextualised)

Trust: Royal Devon and ExeterTrust: Royal Devon and ExeterFrequencyFrequency

SpecialtySpecialtyA&EA&E DentistryDentistry VirologyVirology GeneticsGenetics ObstetricsObstetrics

Peer group averagePeer group average

National averageNational average

Information RequirementsInformation Requirements

• Service area• Incident location• PSI date / time• Country• Incident category• Underlying causes• Contributory factors• Actions

– Planned or taken– Preventative– Minimised harm

• Prevented PSI

• 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

• Age• Paediatric ward• Sex• Ethnic category• Impairment / disability• Specialty• MHCPA• Harm

– Yes / No– Degree– Effect

• Staff type / status / role

Information Requirements - Medication

Information Requirements - Medication

• Stage• Medicine incident type• Other contributory factors• Approved (drug) name• Proprietary (trade) name• Form• Dose and strength• Route

• 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

• BNF classification• Administration

– Intended drug

• Manufacturer• Batch number• Manufactured special?• Registered EU importer

– Re-labelled for UK market

• Clinical trial

Information Requirements - Devices

Information Requirements - Devices

• Type• Current location• Product name• Model• Catalogue number• Serial number

• Type• Current location• Product name• Model• Catalogue number• Serial number

• Manufacturer• Supplier• Batch number• Expiry date• Manufacture date

• Manufacturer• Supplier• Batch number• Expiry date• Manufacture date

Wish ListWish List

• Common definition for patient safety / PSI• Key requirements• Stakeholders

– Specialism– Level of involvement

• Other relevant HL7 messages• Synergistic action plan

• Common definition for patient safety / PSI• Key requirements• Stakeholders

– Specialism– Level of involvement

• Other relevant HL7 messages• Synergistic action plan

chris.foye@npsa.nhs.ukchris.foye@npsa.nhs.uk