A Closer Look at Luton and Dunstable Hospital case study 293.33 KB pdf
- Set up to test practical ways of improving hospital safety and to demonstrate what can be achieved through an organisation-wide approach to safety.
- Ran from 2004-2008.
- Encompassed two phases and 24 hospitals took part.
Ensuring safety and reliable care in the NHS is a massive challenge. While the majority of people are treated without incident, it is estimated that 1 in 10 people admitted to hospital in the UK will experience some sort of harm.
In nearly every case, the problem is caused by unreliable health care sytems and processes.
The Safer Patients Initiative was the first major improvement programme to start addressing the issue of patient safety in the UK. It was complex and large-scale in its approach to improvement, recognising that change needed to take place aross whole organisations an systems rather than focusing on individual incidents. It aimed to create a culture where staff recognise the potential for error, challenge unreliable processes or unsafe care, and feel able to suggest and make improvements.
The initiative was designed with input from the Institute for Healthcare Improvement and focused on improving the reliability of speciic processes of care within four designated clinical areas:
- general ward care
- critical care
- peri-operative care
- medicines management.
In the first phase, four UK hospitals undertook improvement in leadership and the four clinical areas using a predefined measurement framework. They were given the ambitious goal of halving the number of adverse events over two years.
Phase 2 saw 20 more hospitals join, working in pairs to learn from each others' successes and challenges. these trust had two aims: a 30% reduction in adverse events and a 15% reduction in mortality over 20 months.
The initiative generated considerable learning. In particular, that a wider set of methods and approaches are needed to impact on patient safety at an organisational level. It also highlighted the scale of the resources needed to make organisation-wide change, the need to make changes at every level of the system, and the time needed to deliver and embed improvements.