Why is The National Patient Safety Agency using DNV, a risk management company with roots in shipping and the oil and gas industry, as consultants integrated in NPSA's leadership team? Probably because the NPSA is rather particular in its choice of risk management expertise.
In their efforts to improve risk management, NPSA has sought advice from some of the best organizations in the business, including NASA, British Airways and representatives of the nuclear industry.
"It's all about a serious and professional approach to one of the most risky businesses in the world," explains joint chief executive Sue Osborn. Together with Susan Williams, Osborn heads the NPSA, which is a relatively new national organisation within the National Health Service (NHS), working to promote patient safety. Sue Osborn illustrates the risks saying that "If you do a comparative risk assessment on health care, you will find that it is generally as safe as bungee jumping."
40,000 accidental deaths
Even though more than one million patients are treated safely by the NHS every day, health care is far more risky than most industries. Osborn illustrates this with some frightening statistics: "In the western world, 10 percent of all patient care is marked by error, of which five percent are fatal. Some 350 million patients are treated in Britain each year. Studies indicate that in Britain, there are 40,000 deaths annually caused by errors - it is estimated that up to half are preventable."
Treating patients who are ill with potentially harmful drugs, increasingly complex technology, and a large number of people involved creates an exponentially rising risk picture. Fatal accidents, misdiagnoses and mistakes are unavoidable. Indeed, the NHS spends some #450 million on clinical negligence expenditure - annually.
"No one likes to think of it on the operating table, but health services are an error trap for staff to fall in and take the patients with them," says Osborn. Osborn explains, "As health care professionals often literally hold our lives in their hands, we need to think of them as perfect. At the same time, they need the confidence we place in them to work effectively."
Traditionally, medical education usually focuses on how to do things right, and not so much on the risks and mistakes that are also part of the profession. In Britain alone, 1,800 million clinical decisions are made each year, and systems must be developed to manage the unavoidable fact that a certain percent of these decisions are wrong.
Building a risk culture without fear
Working to build a risk - aware culture where the risks are quantified, qualified and understood is paramount in order to start creating a system where trust and confidence can be established. Both patients and staff need to be sure everything is done to prevent avoidable accidents. A scientific approach based on experience from high risk industries might help the individuals' fear of blame and guilt, which sometimes gets in the way of adequate reporting and learning from mistakes.
Helen Hughes, director of operations at the NPSA is responsible for developing a national reporting and learning system: "We have learned from high-risk industries that a steady increase in the number of reported incidents usually results in a decrease in the number of serious accidents that occur. Understanding what goes wrong, combined with systematic learning from such incidents is at the core of a good risk - aware culture. Implementing a culture where it is natural and safe to report incidents without fear takes time. Therefore, we will enable staff to report anonymously if that is the only way they will report to us, so that we can use this information to learn about the most difficult issues in the healthcare system."
The NPSA was established in 2001 to co-ordinate the efforts of reporting, and more importantly, to learn from mistakes and problems that affect patient safety. From the start, it was clear that the NPSA wanted to pioneer a different, somewhat unusual approach. "We couldn't have done this work without the risk assessment expertise from the industry," says Osborn. Following a strong drive from the two Joint Executives to learn risk management from the best, the NPSA tendered for a risk management consultancy. DNV Consulting was chosen.
"By including DNV Consulting on the team, we have been able to identify and quantify the risks, creating an overview before we start working on solutions. And DNV Consulting also takes part when we work out solutions," explains Osborn. Changing a big organisation such as the NHS is a risk in itself, one that calls for risk assessment and cost benefit analyses to find ways of making things work. "We don't want to just send out directives telling everyone what to do. When we find good solutions we want to make sure they work, and this means active support and co-operation with everyone involved."
A risk approach versus an alphabetical one
In practice, this means close co-operation with healthcare professionals in order to find the risk areas that demand attention. For instance, medication errors account for 25 percent of all the errors. Medicines are often stored alphabetically, which means that harmless medicines are placed next to lethal doses of medicine with almost identical names. This illustrates how one system might actually facilitate errors. Such errors can easily be avoided by using a system that is based on risk categories.
Improved methods of labelling, packaging and storing medicines can reduce risks so that hospital staff have one less trap to fall in during a busy day. "Making the right thing the easy thing to do is what this is all about," says Osborn.
As in all industries, new rules and regulations can add to the risks. The convention for drug names is changing to a common naming system for the whole of the European Union. Many generic drug names will change. This may result in confusion among doctors and pharmacists in prescribing and dispensing drugs, and could result in potential adverse effects for patients using drugs. DNV is therefore supporting the NPSA's assessment of risks during the period when drug names change.
When Mrs. Smith is treated as Mrs. Brown
To manage the risk of misidentification, the NPSA is leading a project to develop ways of reducing the risks of wrongsite surgery patient incidents. DNV has supported this work by process mapping the activities before, during and after an operation, facilitating a risk assessment of the process and providing human factors expertise into the process.
Health Care Associated Infections (HCAIs) are resulting in increased stays for patients in hospitals, and in extreme cases, patient fatalities. The estimated cost to the NHS of HCAIs is one billion pounds a year. The NPSA is leading a programme to roll out the use of alcohol hand rubs in NHS hospitals, to improve the hand hygiene of staff and to reduce the incidents of infection. DNV has supported this programme by leading a risk assessment of the usage of alcohol hand rubs and a risk assessment of the proposed test phase of the rollout.
Standardisation of equipment
As is the case with decentralised and big organisations, the various needs and lack of co-ordination across the organisation at some point leads to inefficient solutions. For instance, the NHS' infusion pumps (used to give liquid and medicine intravenously) come in many different varieties and from different vendors. "If we can rationalise, standardise and centralise the purchase and use of these, there is a far better chance that proper training can be given to those who need to operate them. It is just one example of how things can be changed without additional costs, save thousands of lives, and improve safety at the same time," says Helen Hughes.
Shaping an organisation
DNV Consulting's scope of work is general risk management support on a day-to-day basis. This has included participation in the management meetings, risk management advice to the Joint Chief Executives, Directors and NPSA's staff and support and training. Supporting the risk assessments and development of the NPSA's risk management systems and organisation has been an important task.
At the same time, an enterprise risk assessment has been carried out to assess the risks to the NPSA and its ability to reach its goals. The NPSA is a young and fast growing organisation eager to establish a safety culture that can set the standard and support the rest of the NHS in its work to improve patient safety. Joint Chief Executive Sue Osborn is well aware that there will be setbacks and obstacles. Still, she sees this work in a ten-year perspective and is confident that the changes brought about in the first three to five years will give further momentum to this work.