PSSIG Scoping Session Chris Foye Information Architect National

PSSIG Scoping Session Chris Foye Information Architect National Patient Safety Agency, UK 28 th September 2004

Overview • San Antonio – Revisit PSSIG’s scope – Decision tree • Ensure efficient working of PSSIG – Set priorities • Aim – Ensure paper is truly representative – Finalise paper

Agenda • • Assumptions Patient safety / patient safety incident definitions Principles Vision statement / mission statement WHO’s International Patient Safety Alliance Reporting systems Prioritisation Decision tree

Assumptions Goal – improve patient safety Derive PS messages which have universal applicability. Financial, resourcing and time considerations out of scope No consistent view of patient safety and what constitutes a PSI Cannot operate disconnected from the realities of modern health care

Patient safety & patient safety incident definitions Patient safety: The processes by which an organisation reduces the risk and occurrence of harm to patients as a result of their healthcare Patient safety incident: Any unintended or unexpected incident(s) that could have or did lead to harm for one or more persons receiving healthcare services

Principles • Provide context • Unearth assumptions about patient safety – Translate into modelling assumptions • Identify potential work streams – Activities – Prioritisation • Formulate vision statement – Mission statement – Scope

Principles Single Reporting System Patient Safety Centre Leverage Information Sources Observatory External Factors Modelling Assumptions Messaging Assumptions Clinician’s Workflow Research Programme Implement Lessons Learnt Localisation Post-Incident Investigation

Vision statement • Ensure patients receive the safest care possible • Encourage a systemic view • Establish a message model for capturing and transmitting PSI data • Ensure complementary information is directed to the appropriate organisations: – Aid understanding – Provide context – Assist in the analysis and identification of areas of concern. • Embed patient safety related clinical decision support systems to reduce overall system risk.

Mission statement • Standard message model for patient safety – Facilitate reporting and investigation • Work with other SIGs – Ensure messages do not adversely affect patient safety – Decision support mechanisms • Complementary information

WHO’s International Patient Safety Alliance • Recognise need for international representation • PSA recognises that “…no single player has the expertise, funding or research and delivery capabilities to tackle the full range of patient safety issues on a worldwide scale. An international alliance would provide a mechanism to decrease duplication of investment and activities. ” • PSSIG should work with the PSA to: – Raise awareness of the group’s activities – Disseminate key deliverables for review – Seek guidance – Ensure the needs of the international community are catered for

Reporting systems • Review of Central Returns Committee (ROCR) – Over 97 different requests for non-financial information. – “Year-on-year impact on the NHS of supplying nonfinancial data in 2000/2001 was an increase of 74 person years. ” • Unnecessary burden on frontline staff – Double entry – Information silos

Entry point Generic Patient Safety Report M e d i c a t i o n V a c c i n e s D e v i c e s S p e c i a l t i e s I n f e c t i o n s T r a n s f u s i o n s

Prioritisation 1. 2. 3. 4. 5. 6. Individual Case Safety Report Generic Patient Safety Report Sub-Domain Development Incident Investigation Decision Support Complementary Information

chris. foye@npsa. nhs. uk