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Ten for 2010 aims to connect the NHS on patient safety

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I always think of myself as a nurse and, if anyone asks, that is how I proudly describe myself.

My career has been a game of two halves, with 15 years in each. That’s a long game. In the first half, I specialised in paediatric intensive care nursing and, in the second half, in patient safety.

I joined the National Patient Safety Agency in 2003. It was an extremely exciting time, working with people who felt as passionate about patient safety as I did.

The greatest experience to date has been leading the second year of Patient Safety First, a campaign focused on acute care in England and based on social movement principles. I had no idea how much fun and how motivating campaigning is.

Spending the year on Patient Safety First has taught me some fundamental things. First, change on a major scale, in a system as large and complex as the NHS, needs a clear strategic approach. Second, you have to start somewhere and see what you can learn. Making complex things simple is key. Third, connections are important. For a campaign to be successful, connecting individuals within the community - in this case, the NHS - is essential. Campaigns provide a platform for people to connect informally.

‘To add value to high impact actions, to align national policies and as part of 10 for 2010, we will support nurses to reduce harm associated with pressure ulcers and falls’

During the past year, we have connected with people who are brimming with ideas. I regularly meet nurses and doctors who can eloquently talk about the systems approach to patient safety, human factors and how we can improve the safety culture of teams and organisations. I am constantly impressed by their knowledge and commitment. Many are “quiet heroes”. The NHS is full of them; individuals doing their best yet still striving to do it better.

For example, I mentioned above that the campaign was focused on acute care. What has truly inspired me is that 63 per cent of non-acute providers have joined the campaign and are actively taking part. They haven’t sat back and said “this doesn’t apply to me” - they have taken our resources and adapted them for their own use. I met a nurse recently who, rather than be left out, downloaded tools and techniques, taught herself how to do improvement cycles and started using techniques such as briefing and debriefing at the beginning and end of her shift. Clearly, she is one of our quiet heroes.

This year the NPSA will be working with the NHS to hear more about quiet heroes. We will provide a platform for frontline staff to share their ideas and the NPSA will be using web discussion forums, web seminars and masterclasses for staff to join or download and we are even using Twitter.

Also in 2010 the NPSA has decided to focus on doing a few things well and build on our work. Rather than developing new topics, we are going to support you with the ones you have already started. For example, we will continue to work with nurses to improve early detection of the deteriorating patient. We will support standard systems for reviewing clinical observations, and support ward staff to respond to the deteriorating patient. This will be through promoting standardised systems for observations with early warning scoring systems, colour observation charts and critical care outreach teams, as well as better communication. This will be part of ten patient safety programmes called “10 for 2010”.

Ten for 2010: the NPSA’s programme to reduce avoidable harm

  • Reduce harm associated with the deteriorating patient
  • Reduce patient harm associated with the use of anticoagulants
  • Reduce patient harm associated with the use of insulin
  • Reduce bacteraemia associated with central lines
  • Reduce the number of suicides in community health, mental health, prisons and acute care using a suicide prevention toolkit
  • Reduce harm during the intrapartum stage of pregnancy through tools and resources
  • Reduce harm for people with learning disabilities with a focused campaign to raise awareness
  • Reduce harm during the perioperative process using the five steps of safer surgery - briefing, sign in, time out, sign out and debriefing
  • Reduce patient deaths and harm associated with falls
  • Reduce patient deaths and harm associated with pressure ulcers

As reported in Nursing Times, nurses will be central to delivering the high impact actions for nursing and midwifery (news, page 1, 17 November, 2009). To add value to these, to align national policies and as part of 10 for 2010, the NPSA will support nurses to reduce harm associated with pressure ulcers and falls.

One criticism of national bodies is that there appears to be no alignment between them or their initiatives. In 2010, we aim to help nurses make those connections.

If the NHS is a whole system, it needs to get connected. We need to share and learn together. Many individuals and organisations need to share a collective identity and build a movement for change. We need to aspire to a shared goal of creating a movement for patient safety.

Suzette Woodward is director of patient safety at the National Patient Safety Agency

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