Facilities: Patient safety by accident or design

Hospital acquired infections and surgical errors may regularly make the headlines, but accidents are the most commonly reported patient safety incident, according to the latest data from the National Patient Safety Agency.

Patient accidents accounted for 33 per cent of all incidents logged by the NPSA’s National Reporting and Learning System, ranking significantly above treatment and procedure related incidents (10 per cent) and medication (9 per cent), which were the next most common incident types recorded between October 2007 and September 2008.

In total, there were 280,545 reported accidents during those 12 months published in the February 2009 quarterly data summary for England. Most of the reports came from acute trusts and general hospitals (74 per cent), whereas accidents made up 51 per cent of incidents in community settings.

While there are many factors that can contribute to patient accidents, such as medication and the patient’s condition, building design in NHS trusts has an important role in minimising risk, says Patricia Young, the NPSA’s design specialist, whose job in part is to advise trusts and strategic health authorities on how to design hospitals with patient safety in mind.

She says patient accidents reported in the national system tend to cover slips, trips and falls and that trusts should be using the reporting system to increase their awareness of where possible risk and adverse events exist.

“Most falls tend to occur between the bed and the bathroom and in the bathroom itself,” says Ms Young, who suggests there are some basic considerations trusts can make to improve patient safety: wherever possible reduce the distance patients have to travel to use facilities; avoid travel through open spaces, for example, by enabling patients to use a wall for support between the bed and bathroom; and ensure there is adequate patient observation.

“Observation is terribly important to patient safety,” she says. “Traditionally, nursing stations have been centralised in wards, but research has shown a decentralised approach is better, so that nurses are dispersed as widely as possible among patients.”

These may be common sense steps to take, but Ms Young adds that patient safety is “not just about building design, it’s to do with local management and how well these systems are managed in practice”.

The Health Estates Facilities Management Association, which represents 450 NHS estates and facilities managers across England, believes the sector has become far more conscious over recent years of the need to address patient safety issues in building design.

Key to this change has been recognition of the importance of a multidisciplinary approach, according to association national secretary Alison McCree, who says the design process should now not only involve design and planning teams, but include input from clinical groups that can flag up practical issues and, perhaps even more crucially, patients’ views in the form of user groups.

This shift has been spurred by the surge in new NHS building programmes.

“We have all gone through a learning curve and this has been about the importance of seeing services through patients’ eyes,” she says.

Association chair Tim Litherland adds: “I would say involving user groups is now seen as good practice. From my point of view, listening to both departmental staff and talking with service users has brought about a major change in the way we develop the built environment.”

Joe Biggs, director of architecture firm P+HS, which works with the NHS, agrees: “It is essential for designers to try to understand what the problems are. This is part of developing robust, workable solutions.”

Risk assessment

In his experience, the involvement of design teams with patient groups is a fairly recent phenomenon and still “far from the norm”, but he says it is now unusual not to have any engagement with clinical groups and “that does mean a huge improvement in design”.

A multidisciplinary, thorough risk assessment before undertaking building work is also the best way to ensure a return on design investment, says Mr Biggs.

“Identifying where the risks are and really studying situations is the best way to target funding. Although it sounds obvious, if all this upfront work is not done, potentially trusts could be spending money on something that is not the best value,” he says.

One of the design solutions that have been introduced in NHS trusts include the use of colour to signal changes in surfaces, such as steps and slopes.

Mr Litherland says: “You used to have a lot of featureless corridors and one way to improve navigation has been to design in changes in definition.”

Another solution where considerable travel around sites is unavoidable is to design in regular rest points, such as seats along long corridors and courtyards.

“Talking to patient groups this is often one of the issues that comes up,” he says.

From a designer’s point of view, simplicity is the key to avoiding patient accidents.

“Our main role in working with the NHS is designing facilities that are very logically laid out,” says Mr Biggs.

Signage is high on his list of where improvements can be made.

“The NHS, like most organisations, is very bad at implementing logical signage. Other than in the most modern sites there is usually a plethora of confusing and distracting signs. If people are stressed and confused they are more vulnerable to hazards such as trips when their attention is taken away. It is almost over-simplification that is required,” he says.

Frances Healey, National Patient Safety Agency clinical reviewer and lead on its 2007 practice guidance Slips, Trips and Falls, says managers should be more aware of how some medical conditions, such as dementia, can affect the way patients interact with the environment. For example, she says, a square of hazard tape covering a crack in the floor or geometric patterns in tiles can cause the illusion of steps.

“People commonly use materials that look nice, but they should be thinking about how the building works for people who can’t interpret as well.”

Lighting, too, can contribute to accidents, particularly at night when patients’ eyesight adjusts from brightly lit toilets to darker corridors and wards.

“Older patients in particular can be blinded for a few minutes, so although it may be counterintuitive, dimmer lights in toilets are better,” adds Ms Healey.

In primary care, the shift to more community services is presenting opportunities to design in these kinds of solutions afresh.

Mr Litherland says: “I think we’re doing well in quite a lot of new community properties because there’s a better understanding of disability. In the past, access wasn’t that great because you had steps all over the place and ramps were on the side of buildings. In new buildings there is much better use of the site to improve access and make it more integrated.”

Conflicting priorities

This is where Mr Litherland thinks investment in design can best yield a return.

“Getting the design right in terms of accessibility is increasingly important. People are realising that investment in the estate can help the unit to do the job it is supposed to do in terms of minimising ‘did not attends’ and increasing activity.”

However, as the NPSA figures attest, accidents do still happen and both Mr Litherland and Ms McCree concede it is not always easy for managers to balance sometimes conflicting priorities.

“As with everything there is a compromise,” says Mr Litherland. “For example, with floor surfaces you have to be able to clean them effectively, while making sure they are not too slippy and that they look right. There are a lot of different things to think about.”

This is an issue that exercises David Oliver, a consultant geriatrician at the Royal Berkshire foundation trust and a falls expert. He believes some of the measures to meet targets for patient dignity, such as single sex wards and the use of more side rooms for infection control, can be counterproductive to falls prevention, as they reduce the possibilities for observation.

“There is a real tension between privacy and dignity and infection control,” he says.

Ms Healey agrees: “Patient safety is being considered vastly more in building design, but what we struggle with is the balance of priorities.”

Her answer is along the same lines as HEFMA’s: “Have the right people around the table and test models with real people.”

She adds: “People do think about this when designing a brand new building, but it would be a real step forwards if patient safety can be built in whenever there are minor day to day alterations too.”