10 March 2010
Datix teams up with Good Governance Institute to publish new report on patient safety
Key findings reveal that NHS boards should systematically monitor the harm and costs arising from errors in patient care plus include a report on patient safety at every board meeting
Datix, a leading supplier of software for patient safety, risk management, incident and adverse event reporting, has teamed up with the Good Governance Institute (GGI) to publish a new report entitled What every healthcare board needs to understand about patient safety. The research recommends that every NHS board meeting should include a report on patient safety and that NHS executives should systematically consider overall harm and costs arising from errors, the quality of incident management and monitor patterns of adverse events. Aimed at all NHS board members, the Datix sponsored report provides useful insights as well as a useful patient safety, ready-reckoner tool.
Authors Datix Chief Executive, Jonathan Hazan and GGI Director, Andrew Corbett-Nolan worked with NHS and other healthcare colleagues to identify leading governance thinking to then develop a plan governing patient safety. Key findings include:
Boards focus too much on individual Serious Untoward Incidents (SUIs). They should place more focus on systematically considering lower level but often more revealing patterns of adverse events and near misses. Web-based systems should replace manual processes to ensure better access to incident reporting, potentially also allowing patients to report incidents.
Non-executive directors should receive awareness training to help them properly understand risk in a healthcare context. There should be greater clarification of their governance (rather than management) role. Risk experts within healthcare organisations should have greater access to the board. Recent governance thinking has rekindled the debate around whether boards should have a risk committee and a Chief Risk Officer, both reporting directly to the board. Both commissioners and providers should have plans in place to understand the global value of those episodes of care associated with an adverse event.
Jonathan Hazan, chief executive of Datix commented, It is estimated that adverse events may account for the deaths of in excess of 30,000 NHS patients each year this in itself is enough to make safety the prime duty of all on NHS boards. The extent of patient harm and the subsequent cost to the healthcare system are both so significant that boards have to ensure they sufficiently focus on patient safety.
The reports development included sessions with the Care Quality Commission (CQC) and the National Patient Safety Agency (NPSA). A high level symposium at the Royal Society of Medicine reviewed the recommendations.
Before the creation of the NPSA, the business of recording patient safety incidents was inconsistent. In the 1980s and 1990s there was no co-ordinated way of finding out how many incidents were happening, what was involved or the severity of those incidents.
Andrew Corbett-Nolan, GGI director added, The report enabled us to develop a patient safety ready-reckoner or maturity matix as a means by which a board can self-evaluate where its patient safety efforts stand in relation to our recommendations and what actions it could institute. The matrix covers; incident reporting and management, board reports and debate, director development, governance activities, structures and risk expertise, finance and commissioning and governance between organisations (GBO) and partnerships. We hope this short but timely paper helps board members to better under the patient safety problem and start to generate a better standard of discussion and challenge in regard to patient safety.
Jonathan Hazan continued, The current picture is still very patchy. We found one board spending a third of its time on patient safety, while others just consider the issue once a year. Boards need to frame how they look at patient safety from the patients perspective and understand the safety issues that arise as a patient moves through the pathway of care. Within the Datix system, there is the means to access all the information healthcare boards should be looking at. By combining web-based reporting systems with committed professionals within the healthcare sector, we can look forward to a safer environment for patients and staff alike.
To download a copy of the full report, please visit www.datix.co.uk
Datix is a global supplier of software for patient safety, risk management, incident and adverse event reporting. Datix is provided as a standard package but its extensive configuration features make it flexible enough to be tailored to meet the requirements of any healthcare organization worldwide. Founded in 1986, Datix has over 400 customers, which includes more than three quarters of the National Health Service in the United Kingdom and major implementations in Canada and the USA. Datix is headquartered in London, United Kingdom.
To learn more, visit www.datix.co.uk or call +44 (0)20 8971 1971
For further information please contact:
Mary Phillips/Andreina West
Tel: +44 (0)1491 639500