Key findings
- Four hospital sites are making impressive progress at reducing the number of medical mistakes that affect their patients thanks to a four-year, £4.3 million patient safety initiative run by The Health Foundation.
- Findings after a year and a half show that by reducing the number of mistakes, hospitals can lower the number of avoidable deaths that occur.
- One of the hospital sites has seen its adverse event rate fall by 79% in just under a year (from 70 events per 1,000 patient days to 15) which, in international expert opinion, is a dramatic reduction.
- Another has seen its hospital standardised mortality ratio1 fall from above the national average to below average (from 111 in 2003 to 95 by 2005).
- The results are also showing fewer hospital acquired infections.
Context
Across the globe, approximately one in ten patients experiences unnecessary harm or suffering due to mistakes that happen in hospitals.2 Much is known about what works in theory to improve hospital safety but it is difficult to put the theory into practice. Working with experts from the US-based Institute for Healthcare Improvement (IHI), the Safer Patients Initiative is providing the resources and technical expertise needed to drive system-wide changes in four hospital sites so that mistakes are more difficult to make.
Who’s involved and what are they doing?
The hospital sites driving forward the improvements are:
- Conwy and Denbighshire NHS Trust (Wales)
- Down Lisburn Health and Social Services Trust (Northern Ireland)
- Luton and Dunstable Hospital NHS Trust (England)
- NHS Tayside (Scotland).
They are testing out what works to improve care in three settings – on the wards, before, during and after operations, and in critical care. In each of these settings, staff are working with The Health Foundation and IHI on ways of improving infection control, the management of drugs and communication between teams of staff plus staff and patients.
What improvements have the hospitals seen?
Early results from the initiative so far include:
Infection control
- Conwy and Denbighshire has seen impressive reductions in surgical infection rates after testing out ways to ensure patients receive antibiotics at the optimal time. Infections following orthopaedic surgery are currently at 0% after peaking at 7%.
- By introducing new safety standards to reduce the number of infections that patients get through ventilator treatment in intensive care, Conwy and Denbighshire has seen knock-on improvements in terms of reduced mortality rates (from 29.4% to 23.6%), shorter length of stay for patients and a saving of £77,000 in the medicines budget (despite treating 250 more patients in the unit over the last 12 months).
- All the sites report a hand hygiene washing compliance rate on the general wards of over 80% which is helping to reduce hospital acquired infections.
Management of drugs
- Down Lisburn has developed a system for tracking and managing the drugs their patients take which has reduced the number of medication errors. For example, fewer complications are occurring after patients have been prescribed anti-coagulants to thin the blood (the adverse event rate fell from 10 per 1000 doses to less than 4). The system is also linked to GP patient records and is stopping mistakes in the primary care setting.
- Conwy and Denbighshire has seen a 90% reduction in unreconciled medications. This means that 90% of medicines are documented correctly when a patient arrives so the hospital knows what the patient is taking; they are maintained correctly throughout the hospital stay (where appropriate to treatment); and are correct on discharge so that each patient receives the right medication at the right dose.
Communication
- At Luton and Dunstable the development of an early warning ward system is allowing staff to monitor patients’ conditions and to take rapid action if they go into decline. This has led to a fall in the crash call rate from 1% to 0.4% of in-patients, as the rapid response team can now take action sooner to avoid patients developing serious life threatening conditions.
Luton and Dunstable is the first hospital in England to develop a web-based scheme that allows patients to suggest ways of making the hospital safer. - The Chief Executives and senior managers of all four hospital sites conduct weekly walk-rounds to demonstrate their commitment to patient safety and respond to any issues raised by staff and patients within 72 hours.
Future plans
The Health Foundation wants to work with up to 16 more hospital sites to put its patient safety improvement work into practice on a wider scale.
Every hospital is different and although national protocols are important, each hospital will require local solutions. The Health Foundation’s vision is to make the changes work locally and then build up a faculty of experts so that they can teach the work on. The first four hospital sites will advance their work over the next three years whilst sharing their learning with the new hospitals involved in the initiative.
The Health Foundation is inviting interested hospitals to apply for a place on the Safer Patients Initiative from May 2006 with a view to beginning work in early 2007.
For further information please contact:
Jo Parish
The Health Foundation Press Office
Direct: 020 7257 8017
Out of hours: 07921 700 356
Email: pressoffice@health.org.uk
“Making our hospitals the safest in the world is a top priority for the NHS. I am encouraged by the early results from the Safer Patients Initiative and impressed by the reported reductions in avoidable adverse events. Improvements come about not only by changes to systems and procedures but through deeper cultural shifts that cannot occur overnight. This initiative shows the importance of strong hospital leadership that prioritises and takes personal responsibility for improving patient safety.”Sir Ian CarruthersActing Chief Executive of the NHS