It is estimated that over 850,000 incidents harm or nearly harm National Health Service (NHS) hospital patients in the UK each year. Furthermore, on average 40 incidents a year contribute to patient deaths in a single NHS organisation. Incidents include medication errors, infections during treatment on intensive care units, and infections associated with surgery.
The Health Foundation, an independent charity that aims to improve health and the quality of health care for the people of the United Kingdom, believes that patients should not experience unnecessary harm, pain or suffering as a result of an error or medical intervention.
In April 2004, The Health Foundation, together with the Institute for Healthcare Improvement (IHI) launched the Safer Patients Initiative, and in November 2006 the Safer Patients Initiative Phase 2 launched, adding 20 more sites to the initiative.
Acute care trusts from across the UK were encouraged to apply for participation in the initiative via a competitive bidding process. Alongside IHI staff and faculty, international experts will work with the leadership and staff of four acute trusts over a two-year period to help build the trusts' expertise in improving patient safety and to develop them as exemplars from which other hospitals can learn. In taking on the role of exemplars, trusts will develop their own methods designed to spread their learning, helping others to improve patient safety. These spread activities will continue for a further two years with the aim that the sites continue to act as exemplars.
View the original Call for Proposals
Highlights from the work include:
*Results for the Safer Patients Initiative 2 are currently being evaluated. Final results will be posted soon.
At Conwy and Denbighshire NHS Trust, pneumonia on the intensive care unit associated with assisted ventilation has been virtually eliminated from a previous level of 30%. Patients now spend less time in the unit and need fewer medications. This has resulted in a saving of £78,000 in the medicines budget and has also allowed 350 more patients to be treated over the last two years.
NHS Tayside has seen its adverse event (medical mistakes) rate fall by almost three quarters. NHS Tayside’s patient safety team recently won the Top Team award at the Scottish Health Awards 2006 and they have increased their hand hygiene compliance to 96% on the general wards which is helping to reduce hospital-acquired infections.
Down Lisburn Health and Social Services Trust has reduced the number of medication errors following the development of a system for tracking and managing the drugs their patients take. At present, the rate of unreconciled medications is below 10%. This means that 90% of medicines are documented correctly when a patient arrives so the hospital knows what the patient is taking, the medications are maintained correctly throughout the hospital stay, and they are correct on discharge so that each patient receives the right medication at the right dose. The system is also linked to GP patient records and is helping to reduce mistakes in the primary care setting.
Luton and Dunstable Hospital NHS Trust estimates that there are between one and two fewer cardiac arrests per week since the introduction of an early warning score system on the wards. The system allows staff to monitor patients’ conditions and to take rapid action if they go into decline. It has led to a fall in the crash call rate as the rapid response team can now take action sooner to avoid patients developing serious life threatening conditions. The Trust has seen its standardized mortality ratio fall from above the national average to below average (from 111 in 2003 to approximately 90 at present).
