Making healthcare safer for patients

Ensuring the safety of everyone who uses health services is one of the most important challenges facing healthcare today. Research from around the world estimates that one in 10 patients in hospital experiences an incident that puts their safety at risk, and that about half of these could have been prevented.

Through its Safer Patients Initiative, The Health Foundation is working with hospitals in the UK and experts from the US-based Institute for Healthcare Improvement to explore the best ways of making hospitals safer for patients. This briefing provides an update on what has been achieved so far and explains the next steps the Foundation is taking to help improve patient safety in the UK.

Patient safety: the facts

Around 16 million people are admitted to hospital each year in the UK.[1] The majority are treated safely and successfully. But a disturbingly high number will fi nd that something goes wrong with their treatment or care, resulting in unnecessary harm, pain or suffering, and sometimes death.

The UK is not alone in facing this problem – hospital safety is a global problem. Estimates suggest that one in 10 patients in hospital experiences an incident which puts their safety at risk, and that about half of these could have been prevented.[2]

Safer Patients Initiative

The Health Foundation is currently supporting four hospitals in a £4.3 million four-year initiative to test ways of improving healthcare safety on an organisation-wide basis. The hospitals, Luton and Dunstable Hospital NHS Trust; Conwy and Denbighshire NHS Trust; Down Lisburn Health and Social Services Trust; and NHS Tayside, are working with international experts from the Institute for Healthcare Improvement (IHI), to develop their expertise in patient safety. They were selected through a UK-wide competition and began their work in early 2005. The funding has been allocated for project management and technical assistance provided by IHI, an external evaluation and direct support to the four sites.

The ambitious aim of the Safer Patients Initiative is to reduce by half the number of adverse events in each site by October 2006. We also expect to see a related reduction in avoidable hospital deaths.

To achieve this, all four sites are following a programme designed by IHI for the Safer Patients Initiative. Called the ‘change package’, it works on three levels:

• addressing five clinical areas, each containing multiple interventions that have an established and accepted evidence base in the UK (such as better management of patients in intensive care, infection control, preventative antibiotics for surgery and medicines safety)
• teaching methods for quality and safety improvement
• establishing a specific role for the chief executives and senior executive team

In 2006 The Health Foundation announced a further substantial investment in the Safer Patients Initiative. Up to 16 hospitals are expected to participate in this second phase of the initiative.

Early days, but encouraging early results

Achieving improvements in patient safety requires focus, commitment and sustained hard work. Transforming hospitals so that patient safety is a priority across the organisation requires hospital leaders to inspire staff towards this change and to identify champions who will drive improvements throughout.

For example, the chief executives and senior managers of all four hospitals conduct weekly hospital walk-rounds to demonstrate their commitment to patient safety. Based around a series of open questions, these are designed to identify areas for improvement and the chief executives are committed to respond within 72 hours to any issues raised.

Although still early days, the emerging results from the Safer Patients Initiative’s four hospitals are encouraging. They show measurable improvements as well as the less tangible, yet clearly perceptible, changes in culture, behaviour and atmosphere.

All four hospitals are implementing similar changes to their clinical practice and behaviour. Each can also identify specifi c areas of signifi cant progress. Some of these are highlighted in this briefing.

Notes 

1. Yuen P. Offi ce of Health Economics Compendium 17th Edition, 2005–06 London: Offi ce of Health Economics, 2005

2. Sources: Vincent, Neale and Woloshynowych “Adverse events in British hospitals: preliminary retrospective record review” in British Medical Journal Vol 322 3 March 2001 and Emslie, Knox and Pickstone (eds) Improving Patient Safety: Insights from American, Australian and British Healthcare ECRI Europe, 2002

NHS Tayside

Although it is still early in the initiative, at NHS Tayside in Scotland, they are already observing a decrease in the hospital’s mortality rate. Signifi cantly, they are also reporting the fi rst signs of a trend in reducing adverse events. The number of adverse events fell from 70 per 1,000 patient days in October 2004 to 15 in July 2005. The IHI expert faculty view this as a dramatic reduction over a relatively short time period.

NHS Tayside is taking steps to ensure that patients play an integral role in their safety efforts. Working with patient representatives, they are providing training on quality improvement methods used in the hospitals as well as involving the representatives in regular team meetings. The representatives are beginning to raise public awareness about safety issues. Patients are encouraged to consider three questions in order to actively shape and infl uence their quality of care: what is the problem? what can I do to help? what should I take away to do?

NHS Tayside staff have also begun succession planning. The medical and nursing schools are now introducing quality improvement methods to fi rst year students as part of their curriculum. Students have clinical placements based around the Safer Patients Initiative and its change methodologies, ensuring that these practices become integral to their work as doctors and nurses of the future.

Luton and Dunstable Hospital NHS Trust

Luton and Dunstable Hospital NHS Trust has reduced its hospital standardised mortality rate whilst participating in the Safer Patients Initiative. This has taken courage for clinicians and managers to talk openly about methods to achieve this, and has required the sustained input of many staff. In 2003, Luton had a higher than average hospital standardised mortality rate and had already begun taking steps to reduce it prior to apply ing for the Safer Patients Initiative.

However, with the additional impetus from their participation, their rate dropped from 111 in 2003 to 95 by the end of 2005. The trust aims to reduce this further to a rate of 80 in the next two years.

Luton and Dunstable is realising signifi cant improvements in patient safety through using an early warning scoring system on general wards coupled with a new critical care outreach team. The system allows staff to monitor patients’ conditions, pick up those who are going into a decline, and take appropriate action. Using the early warning scoring system has led directly to the early detection and correction of deterioration in patients’ health.

The critical care outreach team consists of intensive care trained nurses who can be called out to give expert advice and, if required, provide emergency treatment. This ensures that patients are given timely and effective treatment to prevent more serious symptoms.

Luton and Dunstable has taken the initiative to develop a patient safety champions collaborative. It has assigned key clinical staff as leaders and advocates for the implemen- ta tion of safer care in each of the fi ve clinical areas. This enables a strategic approach to implementation and spread and facilitates peer-to- peer learning, which is particularly useful between medical staff.

Down Lisburn Health and Social Services Trust

Down Lisburn Health and Social Services Trust has developed a system for tracking and managing the medicines that patients take. This means that fewer mistakes are happening, particularly on admission and discharge of patients. Early results are also showing good progress in reducing harm related to the prescribing and use of anticoagulants in hospital and on discharge. This is being achieved by standardising prescribing practice and designing a clear and easy-to-use system that has now been rolled out to most of the wards across the trust. The team is now considering how it can involve colleagues from community settings to ensure that patients’ medication is properly managed by patients themselves and their GPs.

One of the best ways to avoid infections spreading in hospitals is by staff and visitors washing their hands. The trust is seeing very good compliance to hand washing which is consistently 80 per cent. Their next challenge is to get even higher compliance. Achieving this will need them to take a very different approach to the current awareness campaigns and regular monitoring. Studies have shown that awareness campaigns will only achieve around 80 per cent compliance. To achieve the extra 10–20 per cent, further changes to the care environment may be needed, such as ensuring sinks or gel dispensers are located in the most convenient places.

Conwy and Denbighshire NHS Trust

Early reports from Conwy and Denbighshire NHS Trust show that real progress is being made in reducing infection rates in its intensive care unit (ICU). For instance, they have introduced safety standards (called ‘ventilator care bundles’) to reduce the number of infections that patients get through ventilator treatment. The ICU team managed to obtain a 100 per cent compliance rate in the use of the care bundles.

This led to impressive improve ments: a reduced mortality rate, both within the ICU and on discharge to the wards, a reduced length of stay for patients in intensive care and a reduction in ventilator-acquired infections. Over 12 months, it also saved £77,000 in the medicines budget despite treating more than 250 patients. The trust also reports signs of improve- ment in staff morale and patients’ and carers’ experience of care.

Conwy and Denbighshire is making good progress in improving surgical care. Patients are consistently receiving treatment designed to prevent deep vein thrombosis where clinically indicated, and post- surgical observations designed to ensure proper recovery. For example, the hospital consistently exceeds a 95 per cent goal for patients attaining a normal temperature following surgery, as evidence suggests that this can improve recovery and lead to lower infection rates. They also consistently exceed a 95 per cent goal to ensure patients are given antibiotics within a timely period to optimise their recovery.