Safety in numbers

17 Jan 2023

The importance of taking a holistic, evidence-based approach to patient safety.

Tina Strack, Associate Director for Quality and Development (NCAPOP), HQIP

Patient safety is defined by the World Health Organisation as “…an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient”. The discipline has developed as health care systems have become more complex, but a key element has always been continuous improvement based on learning from mistakes. As such, learning from mistakes requires an environment without blame and fear, as well as an openness to doing things differently. It also requires knowledge and information, which can tell us not only what happened but also highlight how similar incidents might be avoided in the future.

Mistakes are rarely the fault of one individual or incident – systems, processes and culture all play their part”

The HQIP-commissioned National Clinical Audit and Patient Outcome Programme (NCAPOP) includes several programmes that gather data and help the health service to learn from mistakes. These include the National Child Mortality Database (NCMD) and the Clinical Outcome Review Programmes. The latter, in particular, all involve a form of confidential enquiry, which is a ‘deep dive’ into the care provided, usually related to adverse events. An important aspect of this is that it is confidential in nature, and so it enables those close to the care delivered to share information, even that which is clear only with hind sight. The aim is not to assign blame or deem who is at fault, although there is a clear process for rare occurrences when there is a significant cause for concern. Rather, it is about assessing the care provided against best practice, identifying whether the right clinical decisions were made, and where things went wrong. Critically, its main purpose is to establish how mistakes can be avoided in future. Following are some examples of how these programmes have been instrumental in highlighting opportunities to improve care:

Maternal, Newborn and Infant Clinical Outcome Review Programme

• There is much collaboration between the programme and a number of maternity safety initiatives. For example, the Clinical Negligence Scheme for Trusts (CNST) maternity incentive scheme, which allows trusts to recoup some of their annual CNST fees if they can demonstrate that they meet the required safety standard. This includes a requirement to notify all eligible perinatal deaths to the programme within seven working days, and ensure that all required information is completed within one month of death.
• Cardiac disease remains the leading cause of women’s deaths during and after pregnancy and the programme has made many recommendations around cardiac care. Working with the Resuscitation Council, the Obstetric Anaesthetists Association developed an Obstetric Cardiac Arrest Quick Reference Guide which addresses several recommendations from the programme’s findings regarding modifications required for the resuscitation of pregnant women as well as causes of cardiac arrest.
• The 2020 report, Saving Lives, Improving Mothers’ Care, highlighted a statistically significant increase of Sudden Unexpected Deaths in Epilepsy (SUDEP) in pregnant and recently pregnant women, and reviewed these cases in detail. The report made several recommendations for how care for women with epilepsy could be improved, including a call for them to receive risk minimisation advice as well as support to ensure that medications are optimised to control seizure frequency. This work was noted as an important case study in the government policy paper Data Saves Lives. In addition, the pro gramme has been working with the charity SUDEP Action to present findings from Saving Lives, Improving Mothers’ Care to several groups, including the All Party Parliamentary Group on Epilepsy.

Medical and Surgical Clinical Outcome Review Programme

• The programme’s 2015 report Just Say Sepsis! highlighted issues relating to the prompt identification and treatment of sepsis. This work led to the publication of Improving outcomes for patients with sepsis: A cross-system action plan and the follow-up 2017 Second Sepsis Action Plan by NHS England.
• Based on recommendations from its Know the Score 2019 report, further research was undertaken to incorporate the use of artificial intelligence to standardise CT pulmonary angiogram (CTPA) reporting. Their study was well received and published as a peer-reviewed article in European Radiology, which prompted some acute trusts to consider utilising this software.
• At the request of the Medical Director of NHS England and NHS Improvement, the authors of the programme’s Delay in Transit 2020 report were invited to the National Quality Board to discuss findings and consider how improvements could be made. The development of pathways for acute bowel obstruction, working alongside other Royal Colleges, is also being considered.

All of this work is underpinned by the NHS Patient Safety Strategy, an over-arching document that describes how the NHS will continuously improve patient safety by building on the foundations of a safer culture and safer systems. This includes a Patient Safety Incident Response Framework (PSIRF) which represents a significant shift in the way the NHS responds to patient safety incidents, by changing the focus from a reactive and some what bureaucratic process to one which is more proactive and risk based. In PSIRF, there is no distinction between incidents and ‘serious incidents’. Instead “unintended or unexpected incidents which could have or did lead to harm for one or more patients receiving health care” are seen as opportunities for learning and, importantly, not for any other purpose (for example, in dividual performance management, assessment of liability or determining cause of death).

It goes without saying that patient safety is of extreme – if not utmost – importance. There are over 11,000 avoidable deaths in the UK annually from unsafe care (this estimate was prior to the COVID-19 pandemic), with many thousands more patients seriously harmed each year. It is also necessarily complex and multi faceted. The safety researcher, Professor James Reason, states that a safe culture depends on five sub-cultures: Informed, Reporting, Just, Flexible and Learning. In health, the Clinical Outcome Review Programmes provide invaluable intelligence in relation to all of these aspects of safety. Its importance can be summed up by the following quote from a colleague who works in patient safety in NHS England, who says: “The clinical outcome review programmes is a vital part of patient safety across the NHS. The evidence it provides supports learning from mistakes and, crucially, leads to improved care for patients in the future.”

Perinatal clinical quality surveillance model. The Morecambe Bay review, and several other high-profile reviews over the past decade, have highlighted examples of poor maternity care that were not recognised until significant harm had occurred. This led to a renewed focus on how to proactively identify organisations that require support before serious issues arise. The perinatal clinical surveillance model in England is intended to do just that, providing consistent and methodical oversight of all maternity services. More specifically, it aims to gather ongoing insights, to inform learning and improvements in the delivery of perinatal services. The system is designed to provide oversight at all levels, ranging from local hospitals, Local Maternity Systems (LMS) and Integrated Care Systems through to regional and national levels. The work of MBRRACE-UK, who run the Maternal, Newborn and Infant Clinical Outcome Review Programme, forms part of discussions at Trust Boards – and then the lessons learned and themes emerging are used by both healthcare providers and planners to inform change. Any trust, where there is a cluster or outlier of cases, is flagged to the surveillance system, so that support can be provided. MBRRACE-UK also sits on the national Maternity Safety Surveillance and Concerns Group (MSSCG), ensuring that the intelligence and learning from the outcome review programme feeds into national strategy.

This article was originally featured in HQIP’s quality improvement magazine, CORNERSTONE volume 1