CfH says patient safety work has progressed

Connecting for Health has worked hard to ensure its clinical software design meets patient safety requirements after a review conducted four years ago found that the National Programme for IT was not pro-actively addressing safety.

Speaking at the Healthcare Computing conference, Maureen Baker, CfH’s national lead for clinical safety, said: “The main findings four years ago were that CfH were not identifying safety as a benefit to drive the programme. They conducted no formal risk assessments and had no formal safety management system. The reliance was on clinicians to instinctively address patient safety problems.”

The research conducted by Mark Bolt, a risk management specialist at DNV, was commissioned by the National Patient Safety Agency and the Department of Health ahead of major deployments under the National Programme for IT.

Bolt concluded in the unpublished study that “NPfIT was not addressing safety in a structured pro-active manner that others would.”

Baker said that as a result of this report, CfH approached the National Patient Safety Agency, where she was working, and she was appointed as the new national lead for clinical safety.

She told E-Health Insider: “As a result of the report, CfH came to NPSA and asked for help with addressing these concerns, which is how I came to be appointed, and work on making patient safety a core element of the National Programme effectively began eliminating the reliance on anyone instinctively knowing of danger to patient safety and making sure training was provided to ensure risks are identified immediately and dealt with”.

Under Baker’s leadership, CfH has now trained over 400 staff, almost half of whom are clinicians, on the principles of safety and risk. A new governance structure introduced is also helping to ensure proper mechanisms for dealing with issues.

She said: “We now have safer IT projects. A clinical safety group administers a clinical risk management system at each site. CfH run a certificate of authority scheme before any system can be implemented ensuring a common safety gateway.

“We also have a pro-active safety incident management process, because things can go wrong and we have to accept this. When it happens, we have to identify it and take swift action. As the incident is noticed, it is passed to duty staff, who are available 24/7, and have to assess the problem, agree a fix and hand the system back as soon as possible.”

Where possible, fixes are made within 24 hours and harm removed by any means necessary, including switching a system off. In the two and a half years, this has been running, CfH has dealt with just under 300 incidents, mostly PACS related.

As well as safety issues with clinical systems, Baker and her team are also working on other projects including blood safety IT pilots, mandating the NHS number, a VTE risk assessment tool and safe electronic handovers.

Bolt was re-commissioned last year to do a new study, and Baker said: “There is still work to do. Gaps and improvements need to be addressed but the conclusion was we had made considerable movement, and with these major work streams underway, we are doing world leading work on safety in the NHS, and healthcare in general.”