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The National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency (NPSA) are collaborating on a pilot project to produce guidance on cost-effective interventions to prevent or mitigate patient harm in the NHS. This follows recommendations made in Safety First, the CMO’s 2006 report,1 which reaffirmed the place of patient safety at the heart of the healthcare agenda.

The pilot project, which will be carried out between April and November 2007, will assess evidence on clinical and cost-effectiveness and produce recommendations for the NHS of the following safety interventions:

• systems based and IT based interventions in medicines reconciliation

• the prevention of ventilator-associated pneumonia (VAP)

Safety guidance is expected to be issued to the NHS in November 2007.

The draft scopes (which define what the safety solution will cover and to whom it will apply) for both of these topics are currently out for consultation; more information can be found at www.nice.org.uk.

Andrew Dillon, Chief Executive of NICE said: “This is a very exciting opportunity for NICE. Our extensive experience will stand us in good stead for developing guidance on new safety solutions for the NHS. The core principles we apply to all guidance development - the use of independent expert committees, genuine public consultation and an open decision-making process - will be applied to this project. We are confident that the resulting guidance will make an important contribution to realising the CMO’s aim that patient safety is at the very core of NHS policy and NHS care.

”Dr Helen Glenister, Deputy Chief Executive, NPSA said: ”This is a unique opportunity for the NPSA to work with NICE, and with others, to put patient safety at the top of the health agenda. Collaborative working is essential to putting patient safety first, and the NPSA is delighted to be part of this pilot project. We’re looking forward to building on our existing learning, feeding back patient safety data from our Patient Safety Observatory and National Reporting and Learning System and sharing knowledge in order to reduce risk to patients. Everyone in the NHS wants to provide the best and safest possible care for patients, and we want to help develop the most effective guidance possible to support the service in providing that care.

For more information call Sarita Tamber on 0207 067 5915 or the NICE press office on 0207 067 5900 or Anna Jefferson at the NPSA on 0207 927 9357.

1 Safety first: a report for patients, clinicians and healthcare managers, DH, December 2006

1. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

2. NICE produces guidance in three areas of health:

• public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector

• health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS

• clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

The National Patient Safety Agency (NPSA) helps the NHS in England and Wales learn from its mistakes so that it can improve patient safety. We do this by collecting reports on errors and other things that go wrong in healthcare so that we can recognise national trends and introduce practical ways of preventing problems. We don’t investigate individual cases or complaints, but we do listen to public concerns and use what they say to improve safety.

3. As a result of the review of patient safety commissioned by the Chief Medical Officer1, the National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency (NPSA) were asked to develop and evaluate a pilot project for the production of a technical solution to address patient safety problems, which will form guidance for the NHS. NICE’s core principles of guidance development will be applied to the project. These principles include:

• A comprehensive evidence base

• Independent advisory committees

• Clinical and patient expert input

• Transparent process and decision making

1 Safety first: a report for patients, clinicians and healthcare managers, DH, December 2006

• Genuine consultation

• Effective dissemination and implementation

• Regular review.

4. Medicines reconciliation is a long standing problem causing medication errors and potential harms to patients.

5. Medicines reconciliation has been defined by Institute of Healthcare Improvement (IHI) as “being the process of identifying the most accurate list of a patient’s current medicines – including the name, dosage, frequency and route – and comparing them to the current list in use, recognising any discrepancies, and documenting any changes, thus resulting in a complete list of medications, accurately communicated.” (2005)

6. Ventilator-associated pneumonia is a primary problem in intensive care units, and causes complications in patients receiving mechanical ventilation.

7. Ventilator-associated pneumonia is a medical condition that results from infection which floods the small, air-filled sacs (alveoli) in the lung responsible for absorbing oxygen from the atmosphere.

8. For an overview of the patient safety pilot process go to the NICE website at http://www.nice.org.uk/PatientSafetyPilot.