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National Patient Safety Agency

New initiative unveiled aimed at reducing harm to patients

 28 May 2010


The National Patient Safety Agency has today announced plans to reduce levels of harm in 10 high risk patient safety areas.


This week, Director of Patient Safety Dr Suzette Woodward launched the 10 for 2010 initiative which identifies 10 high risk clinical areas and outlines actions organisations need to take to reduce them from re-occurring.
The drive, announced at this year’s Patient Safety Congress in Birmingham, is relevant to all care settings.


Opening this year’s congress, Dr Woodward said 10 for 2010 aims to significantly reduce levels of harm within the NHS: “One patient needlessly being harmed by a safety incident is one patient too many.


“By expanding our work in this way, we can transform the patient safety culture.  10 for 2010 is about working together to reduce instances of harm to all patients who use NHS services.”


The ten areas that comprise 10 for 2010 include reducing pressure ulcers, preventing falls from occurring and ensuring clinicians are aware of the correct dosage of insulin when administering the drug to a patient.


Each of the ten high risk areas will have a clinical lead who will work with NHS organisations across England and Wales to raise awareness and implement working practices. 


Dr Woodward added: “We know this approach has worked.  By concentrating our effort in 10 of the most high risk areas, we will be able to make sure our effort is being effectively implemented by NHS organisations and supported by us.


“We will provide support and leadership using targeted campaigns to drive changes to our 10 key areas of clinical activity.”



Notes to editors


10 for 2010 includes:


Deterioration – To reduce harm associated with deterioration through improved recognition of and response to deterioration.
The NPSA Deterioration Programme will build on and continue the success of the Patient Safety First Deterioration Intervention, by supporting the implementation of evidence based guidance and tools, and drawing on the expertise of clinicians already making great improvements.  In support of existing tools, links will be made with staff in non-acute sectors to find and share examples of adaptations of acute focused implementation tools.  These areas will include mental health, child health, maternity and the community. 

Falls - To reduce harm from falls without compromising dignity, independence and rehabilitation.  Using the10 for 2010 common implementation principles and actions, the falls programme will achieve its vision and aims by working with local trusts and organisations to:
• Establish a falls prevention group
• Improve analysis and learn from falls
• Train and develop staff in falls prevention
• Create a safe environment
• Develop post fall protocols – care and secondary prevention
• Conduct in-depth assessment and multifaceted care plans
• Ask about falls on every admission
• Avoid unnecessary hypnotic/sedative medication
• Ensure patients have appropriate footwear
• Ensure call bell visible and within reach

Insulin - To enable healthcare organisations to reduce the number of serious incidents following the unsafe use of insulin.  The insulin programme will achieve its vision and aims by working with local trusts and organisations to:
• Promote awareness of risk with their clinical staff using RRR, PSA and other NPSA materials
• Implement guidance in the How to Guide and national guidelines & RRR. – PDSA cycles of change
• Use NPSA support materials and online community to help implementation, discuss problems, sustain change
• Use a design guide to introduce a safer inpatient prescription chart
• Use an e-learning module to train staff
• Test an Insulin passport using PDSA cycles of change
• Implement national patient held information / insulin passport

Anticoagulation - Atrial fibrillation (AF) is a major predisposing factor to stroke.  Each year it accounts for some 12,500 strokes in England.   Using the10 for 2010 common implementation principles and actions, the anticoagulation programme will achieve its vision and aims by working with local trusts and organisations to:
• Check CAS implementation status
• Review action plans
• Test examples of good practice locally
• Work with local professional organisations
• Undertake cultural assessment e.g. MaPSaF
• Highlight examples of good practice both locally and nationally
• Identify and use local clinical champions
• Co-ordinate improvement methodology locally
• Provide feedback on safety indicators to providers
• Routinely identify safety indicators for incorporation into contacts
• Proactively consider safety when discussing contracts and monitoring
• Actively monitoring contracts against safety indicators
• Promote NICE guidelines locally
• Highlight relevant elements of ‘How to’ guides to frontline staff

Pressure Ulcers - Patient position, nutrition and hydration and monitoring and assessment are recognised as being key to the prevention of pressure ulcers. Evidence from the National Reporting and learning Service suggests that this is an area where much harm is reported and that the NPSA is in a unique position to address.

Using the10 for 2010 common implementation principles and actions, the pressure ulcers programme will achieve its vision and aims by working with local trusts and organisations to:
• Raise awareness and increase reporting and signpost existing guidance on pressure ulcer prevention through publications and collaboration with the Your Turn Campaign
• Identify and disseminating barriers to implementation of guidance and best practice
• Identify and disseminate good practice in pressure ulcer prevention
• Promote and participate in  communities of special interest for pressure ulcer prevention
• Use a  “How to” guide for pressure ulcer prevention published by the NPSA
• Engage with other national/ local organisations and campaigns to add value and support to existing activity in pressure ulcer prevention
• Improve quality and safety by using PDSA cycles for interventions that impact on pressure ulcer prevention.


Five Steps to Safer Surgery - A core set of safety checks, to be initiated a safety critical time points within the patients care pathway,  has been identified in the form of a WHO Surgical Safety Checklist for use in any operating theatre environment with the caveat that it can be adapted to fit local practice.
It has become clear, from experience and feedback, over the last year that the addition of team brief and debriefing sessions at the beginning and end of theatre lists are key to succeeding in the cultural change required.

Using the10 for 2010 common implementation principles and actions, the ‘five steps to safer surgery’ programme will achieve its vision and aims by working with local trusts and organisations to:
• Implement the use of five steps to safer surgery
• Improvement in team culture
• Reduce the number of surgical site infections
• Reducing the number of Never Events
• Reducing the number of venous thromboembolisms


Reducing Avoidable Harm in Childbirth - The commonest cause of maternal death due to pregnancy (direct cause) is thromboembolism and the commonest cause of maternal death due to underlying conditions (indirect cause) is cardiac disease.  Using the10 for 2010 common implementation principles and actions, the ‘reducing avoidable harm in childbirth’ programme will achieve its vision and aims by working with local trusts and organisations to:
• support clinical leaders, managers and supervisors of midwives in maternity services to reduce avoidable harm and death
• Create an integrated approach across all initiatives and organisations
• Support women and their families to participate fully in local patient safety improvement programmes through facilitated workshops and 1:1 meetings
• Support women and their families to share their stories and experiences with maternity services providers. Focus on positive stories where actions have made a difference to the outcome.
• Increase awareness of the childbirth programme aims and interventions
• Work with front-line obstetricians, midwives and other health professionals  to increase the reliability of specific clinical practices using evidence based guidance


Suicide Prevention within the Health Community - This is an important area to focus on because 96% of patient suicides take place in the community and 74% of suicides are of those not in touch with the mental health service in the previous 12 months. In addition to this there is increasing complexity in terms of discharge planning and problems of communication between primary to secondary mental health services.
• Raise awareness of the suicide prevention programme aims and interventions leading to changes in behavior and practice that improve leadership and multidisciplinary working in the prevention of suicide
• To maintain the suicide prevention working group and to introduce representation from primary & secondary care networks for sharing and learning relating to the care of the health community during times of crisis and during contact with health care service/ organisations across England and Wales. 
• Involve service users, carers and families as key partners in all elements of the suicide prevention programme


Matching Michigan - The aim of this area of the programme is to minimise the rate of Central Venous Catheter Blood Stream Infections (CVC-BSI) within adult and paediatric ICUs in England. The Matching Michigan programme will do this by:
• Providing a standardised data definition, data items, and measurement methodology for CVC-BSI
• Measure and minimise the rate of CVC-BSI
• Provide an interactive web-based tool for reporting infections in critical care (RICC) for ICUs to compare their CVC-BSI data over time and to their peers
• Implement both technical and non-technical interventions

Learning Disabilities - People with learning disabilities have particular issues in relation to patient safety.  They are a vulnerable group of patients who are often missed when considering the risks in healthcare.  The NPSA has launched an improvement programme, 10 for 2010 and within this programme there will be another Patient Safety First Week from 6 September to 12 September.  During this week, the Patient Safety teams at the NPSA will highlight the patient safety impact for patients with learning disabilities to raise awareness in all care settings.


1. Media enquiries to the NPSA Press Office:

Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk

Dominic Stevenson – 020 7927 9351 / dominic.stevenson@npsa.nhs.uk


Out of hours – 0788 411 5956


2. The National Patient Safety Agency (NPSA) is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.nrls.npsa.nhs.uk.